Protein Tyrosine Kinase Inhibitors

Speaker Huang Kuo-Chun

Date 2011-11-15

Cells communicate

Gap Junctions and CAMs

bull Protein channels - connexinbull Direct flow to neighbor

ndash Electrical- ions (charge)ndash Signal chemicals

bull CAMs ndash Need direct surface

contactndash Signal chemical

Direct and local cell-to-cell communication

Paracrines and Autocrines

bull Local communication bull Signal chemicals diffuse

to targetbull Example Cytokines

ndash Autocrinendashreceptor on same cell

ndash Paracrinendashneighboring cells

Figure 6-1c Direct and local cell-to-cell communication

bull Signal Chemicalsbull Made in endocrine

cellsbull Transported via

bloodbull Receptors on target

cells

Long Distance Communication Hormones

Long distance cell-to-cell communication

Long Distance Communication Neurons and Neurohormones

Long distance cell-to-cell communication

Signal Pathways

bull Signal molecule (ligand)bull Receptorbull Intracellular signalbull Target proteinbull Response

Signal pathways

bull Ligand- gated channelbull Receptor enzymesbull G-protein-coupledbull Integrin

Membrane Receptor Classes

Membrane Receptor Classes

Four classes of membrane receptors

Signal Transduction

bull Transforms signal energy

bull Protein kinasebull Second messengerbull Activate proteins

ndash Phosporylationndash Bind calcium

bull Cell response

Biological signal transduction

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Cells communicate

Gap Junctions and CAMs

bull Protein channels - connexinbull Direct flow to neighbor

ndash Electrical- ions (charge)ndash Signal chemicals

bull CAMs ndash Need direct surface

contactndash Signal chemical

Direct and local cell-to-cell communication

Paracrines and Autocrines

bull Local communication bull Signal chemicals diffuse

to targetbull Example Cytokines

ndash Autocrinendashreceptor on same cell

ndash Paracrinendashneighboring cells

Figure 6-1c Direct and local cell-to-cell communication

bull Signal Chemicalsbull Made in endocrine

cellsbull Transported via

bloodbull Receptors on target

cells

Long Distance Communication Hormones

Long distance cell-to-cell communication

Long Distance Communication Neurons and Neurohormones

Long distance cell-to-cell communication

Signal Pathways

bull Signal molecule (ligand)bull Receptorbull Intracellular signalbull Target proteinbull Response

Signal pathways

bull Ligand- gated channelbull Receptor enzymesbull G-protein-coupledbull Integrin

Membrane Receptor Classes

Membrane Receptor Classes

Four classes of membrane receptors

Signal Transduction

bull Transforms signal energy

bull Protein kinasebull Second messengerbull Activate proteins

ndash Phosporylationndash Bind calcium

bull Cell response

Biological signal transduction

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Gap Junctions and CAMs

bull Protein channels - connexinbull Direct flow to neighbor

ndash Electrical- ions (charge)ndash Signal chemicals

bull CAMs ndash Need direct surface

contactndash Signal chemical

Direct and local cell-to-cell communication

Paracrines and Autocrines

bull Local communication bull Signal chemicals diffuse

to targetbull Example Cytokines

ndash Autocrinendashreceptor on same cell

ndash Paracrinendashneighboring cells

Figure 6-1c Direct and local cell-to-cell communication

bull Signal Chemicalsbull Made in endocrine

cellsbull Transported via

bloodbull Receptors on target

cells

Long Distance Communication Hormones

Long distance cell-to-cell communication

Long Distance Communication Neurons and Neurohormones

Long distance cell-to-cell communication

Signal Pathways

bull Signal molecule (ligand)bull Receptorbull Intracellular signalbull Target proteinbull Response

Signal pathways

bull Ligand- gated channelbull Receptor enzymesbull G-protein-coupledbull Integrin

Membrane Receptor Classes

Membrane Receptor Classes

Four classes of membrane receptors

Signal Transduction

bull Transforms signal energy

bull Protein kinasebull Second messengerbull Activate proteins

ndash Phosporylationndash Bind calcium

bull Cell response

Biological signal transduction

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Paracrines and Autocrines

bull Local communication bull Signal chemicals diffuse

to targetbull Example Cytokines

ndash Autocrinendashreceptor on same cell

ndash Paracrinendashneighboring cells

Figure 6-1c Direct and local cell-to-cell communication

bull Signal Chemicalsbull Made in endocrine

cellsbull Transported via

bloodbull Receptors on target

cells

Long Distance Communication Hormones

Long distance cell-to-cell communication

Long Distance Communication Neurons and Neurohormones

Long distance cell-to-cell communication

Signal Pathways

bull Signal molecule (ligand)bull Receptorbull Intracellular signalbull Target proteinbull Response

Signal pathways

bull Ligand- gated channelbull Receptor enzymesbull G-protein-coupledbull Integrin

Membrane Receptor Classes

Membrane Receptor Classes

Four classes of membrane receptors

Signal Transduction

bull Transforms signal energy

bull Protein kinasebull Second messengerbull Activate proteins

ndash Phosporylationndash Bind calcium

bull Cell response

Biological signal transduction

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

bull Signal Chemicalsbull Made in endocrine

cellsbull Transported via

bloodbull Receptors on target

cells

Long Distance Communication Hormones

Long distance cell-to-cell communication

Long Distance Communication Neurons and Neurohormones

Long distance cell-to-cell communication

Signal Pathways

bull Signal molecule (ligand)bull Receptorbull Intracellular signalbull Target proteinbull Response

Signal pathways

bull Ligand- gated channelbull Receptor enzymesbull G-protein-coupledbull Integrin

Membrane Receptor Classes

Membrane Receptor Classes

Four classes of membrane receptors

Signal Transduction

bull Transforms signal energy

bull Protein kinasebull Second messengerbull Activate proteins

ndash Phosporylationndash Bind calcium

bull Cell response

Biological signal transduction

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Long Distance Communication Neurons and Neurohormones

Long distance cell-to-cell communication

Signal Pathways

bull Signal molecule (ligand)bull Receptorbull Intracellular signalbull Target proteinbull Response

Signal pathways

bull Ligand- gated channelbull Receptor enzymesbull G-protein-coupledbull Integrin

Membrane Receptor Classes

Membrane Receptor Classes

Four classes of membrane receptors

Signal Transduction

bull Transforms signal energy

bull Protein kinasebull Second messengerbull Activate proteins

ndash Phosporylationndash Bind calcium

bull Cell response

Biological signal transduction

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Signal Pathways

bull Signal molecule (ligand)bull Receptorbull Intracellular signalbull Target proteinbull Response

Signal pathways

bull Ligand- gated channelbull Receptor enzymesbull G-protein-coupledbull Integrin

Membrane Receptor Classes

Membrane Receptor Classes

Four classes of membrane receptors

Signal Transduction

bull Transforms signal energy

bull Protein kinasebull Second messengerbull Activate proteins

ndash Phosporylationndash Bind calcium

bull Cell response

Biological signal transduction

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

bull Ligand- gated channelbull Receptor enzymesbull G-protein-coupledbull Integrin

Membrane Receptor Classes

Membrane Receptor Classes

Four classes of membrane receptors

Signal Transduction

bull Transforms signal energy

bull Protein kinasebull Second messengerbull Activate proteins

ndash Phosporylationndash Bind calcium

bull Cell response

Biological signal transduction

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

Prot

ein

Labo

rato

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nive

rsity

of C

open

hage

n

Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

ein

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rsity

of C

open

hage

n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Membrane Receptor Classes

Four classes of membrane receptors

Signal Transduction

bull Transforms signal energy

bull Protein kinasebull Second messengerbull Activate proteins

ndash Phosporylationndash Bind calcium

bull Cell response

Biological signal transduction

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Signal Transduction

bull Transforms signal energy

bull Protein kinasebull Second messengerbull Activate proteins

ndash Phosporylationndash Bind calcium

bull Cell response

Biological signal transduction

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Signal Amplification

bull Small signal produces large cell response

bull Amplification enzymebull Cascade

Signal amplification

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

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ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Receptor Enzymes

bull Transductionbull Activation

cytoplasmicndash Side enzyme

bull Example Tyrosine kinase

Tyrosine kinase an example of a receptor-enzyme

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

Prot

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

More than 70 of the known oncogenes and proto-oncogenes involved in cancer code for PTKs The importance of PTKs in health and disease is further underscored by the existence of aberrations in PTK signaling occurring in inflammatory diseases and diabetes

Protein Tyrosine Kinase

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

Prot

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open

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n

Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

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n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

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open

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n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

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rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

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n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

腫瘤血管增生

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

腫瘤淋巴管增生

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Signalling Pathways

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

These enzymes are involved in 1cellular signaling pathways2regulate key cell functionssuch as proliferation differentiation anti-apoptotic signaling and neurite outgrowth

Unregulated activation of these enzymes through mechanisms such as 1point mutations or 2over-expression can lead to various forms of cancer as well as benign proliferative conditions

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

Prot

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

The total number of PTKs does not exceed 1000

There are two main classes of PTKs ( Of the 91 protein tyrosine kinases identified thus far)

1receptor receptor tyrosine kinases ( 59 ) [RTK]and 2cellular or non-receptor tyrosine kinases ( 32 )[The receptor-associated tyrosine kinases ]

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

Prot

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open

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n

Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

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n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

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open

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n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

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open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

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n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Receptor PTKs possess an extracellular ligand binding domain a transmembrane domain and an intracellular catalytic domain

TK Intracellular Catalytic Domain

Extracellular Ligand Binding Domain

Transmembrane Domain

membrane

1RTK structure

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

bull RTK family includes the receptors for many growth factorsndash EGF (epidermal growth factor)ndash IGF1 (insulin-like growth factor 1)ndash PDGF (platelet-derived growth factor)ndash FGFs (fibroblast growth factors)ndash VEGF (vascular endothelial growth factor)ndash And the like

2 Ligands of RTK

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

Prot

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

The transmembrane domain anchors the receptor in the plasma membrane while the extracellular domains bind growth factors

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

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ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

The extracellular domains are comprised of one or more identifiable structural motifs including cysteine-rich regions fibronectin III-like domains immunoglobulin-like domains EGF-like domains c-adherin-like domains Factor VIII-like domains glycine-rich regions leucine-rich regions acidic regions kringle-like domains and discoidin-like domains

3Extracellular domain

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

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ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

RTK Subclasses

EGFRHER2neuHER2HER4

I-RIGF-1RIRR

PDGFRαPDGFRβCSF-1RKITFLK2FLT3

VEGFR1VEGFR2VEGFR3

FGFR-1FGFR-2FGFR-3FGFR-4

CCK4 TRKATRKBTRKC

METRON

EPHA1-EPHA8EPHB1-EPHB7

AXLMERTYRO3

TIETEK

RYK DDR-1DDR-2

RET ROS LTKALK

ROR1ROR2

MUSKMDK4

AATYKAATYK2AATYK3

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

ein

Labo

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nive

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of C

open

hage

n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

20151021 24

Type I 含半胱胺酸的2個重複序列Tyep II 異四聚體結構Tyep III由5個Ig構成Type IV 由3個Ig構成

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

4 Three ways to cross-link receptors

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

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ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

The intracellular kinase domains of receptor PTKs can be divided into two classes those containing a stretch of amino acids separating the kinase domain and those in which the kinase domain is continuous

5 Intracellular domain

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

ligand induced dimerizationautophosphorylation by cross-phosphorylation

Dimerization and Autophosphorylation of Receptor Protein-Tyrosine Kinases

Activation of the kinase is achieved by ligand binding to the extracellular domain which induces dimerization of the receptors Receptors thus activated are able to autophosphorylate tyrosine residues outside the catalytic domain via cross-phosphorylation The results of this auto-phosphorylation are stabilization of the active receptor conformation and the creation of phosphotyrosine docking sites for proteins which transduce signals within the cell

6 Dimerization

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

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ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

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Ligand-binding results in receptor dimerization or activation of a pre-existing dimer

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

These enzyme domains are normally inactive but when brought together by receptor clustering they are able to activate each other by trans-phosphorylation Once activated these tyrosine kinases can phosphorylate and activate other cytoplasmic signaling molecules

Receptor Protein-Tyrosine KinasesReceptor with Intrinsic Tyrosine Kinase Activity

7 Intrinsic Tyrosine Kinase Activity

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

8Role of PTPs in c-Src Activation

From Hunter (2001) Nature 411355

Extracellular signal

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Signaling proteins which bind to the intracellular domain of receptor tyrosine kinases in a phosphotyrosine-dependent manner include 1RasGAP 2phosphatidylinositol-3acute-kinase (PI3-kinase) 3phospholipase C-γ 4phosphotyrosine phosphatase SHP and 5adaptor proteins such as Shc Grb2 and Crk6And downstream effects including stimulation of other tyrosine kinases elevation of intracellular calcium levelsactivation of serinethreonine kinases

9 Bind to Kinase domain

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Association of Downstream Signaling Molecules with Receptor Protein-Tyrosine

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Adaptor Proteins

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

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n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

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n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

SH2 amp pY peptide

phosphorylation

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

ein

Labo

rato

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nive

rsity

of C

open

hage

n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

ein

Labo

rato

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rsity

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open

hage

n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

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nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

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rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

pY

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

ein

Labo

rato

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nive

rsity

of C

open

hage

n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

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nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Adaptor proteins are specialized signaling molecules that usually have no enzymatic activity themselves

Adaptor Proteins

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

Ex

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

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EGF-receptor signaling

Human carcinomas frequently express high levels of receptorsin the EGF receptor family In the last two decades monoclonalantibodies (MAbs) which block activation of the EGFR andErbB2 have been developed A humanized anti-ErbB2 MAbis active and was recently approved in combination withpaclitaxel for the therapy of patients with metastatic ErbB2-overexpressing breast cancer

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RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

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RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

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AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Prot

ein

Labo

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open

hage

n

RASSignaling downstream of Ras activation

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

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rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

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of C

open

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n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

RTKRTK can also activatephospholipid kinase ndashPI-3 kinase

RTK can also activatePLCγ

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

PP

PP

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

ANGIOGENESIS

Survival Proliferation Migration

PLC FAKPI3-K Ras

IP3PKC AKT Paxillin MAPK

VEGF

VEGFR binding and activation

Endothelial cellactivation

VEGF A Key Mediator of Angiogenesis

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Cellular PTKs are located in the cytoplasm nucleus or anchored to the inner leaflet of the plasma membrane They are grouped into eight families SRC JAK ABL FAK FPS CSK SYK and BTK Each family consists of several members Structures 1homologous kinase domains (Src Homology 1 or SH1 domains) 2some protein- protein interaction domains (SH2 and SH3 domains)Other unique domains

Functions 1SRC are involved in cell growth2 FPS PTKs are involved in differentiation 3ABL PTKs are involved in growth inhibition 4FAK activity is associated with cell adhesion 5JAKs which phosphorylate the transcription factors STATs Which interact with Some members of the cytokine receptor pathway

6Still other PTKs activate pathways whose components and functions remain to be determined

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

AnnuRevCell DevBiol135131997

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Schematic presentation of the cytoplasmic protein tyrosine kinase families The major domains of the mammalian nontransmembrane protein tyrosine kinases are indicated SH Src homology domain

1

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Prot

ein

Labo

rato

ry U

nive

rsity

of C

open

hage

n

AktPKB ndash cell survival kinase

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Mechanism of PTK Activation

bull Autophosphorylation serves two distinct functions in the receptor activation processndash Receptor catalytic activity through proper

active site configurationndash Creation of binding site for downstream

signaling proteins phosphotyrosines are available as recruitment sites for proteins

bull Containing Src homology 2 (SH2) domain or phosphotyrosine-binding domains

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Autoinhibition and Activation

20151021 50

Downstream signaling proteins

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

為什麼 Signal Transduction

總是圍繞在Phosphorylation

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Signalling Pathways

Cell 100 57ndash70 2000

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Role of Ras protein in a central growth factor activationpathway

Tyrosine

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Why phosphorylation

1 Causes allostericchanges in protein

2 negative charges3 Attracts positive side

chains (Lys Arg)4 Occurs on Serine

threonine and tyrosine

Structure function relationship

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

General kinase structure

1 Often N and C-terminal lobes2 N-terminal ATP binding site3 Activating catalytic loop

(phosphorylated)4 Short sequences (red

arrowheads) are unique to specific kinase and may determine substrate specificity

Cyclic AMP-dependent kinase (PKA)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

ErbB Receptor Signaling Network

Yarden and Sliwkowski nature reviews 2001

bull EGFR (ErbB1) is one of four members of ErbB receptor family

bull ErbB family trigger a rich signaling network including Erk and Akt pathways

12 3 4

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

The phosphotyrosines are dockingsites for a variety of proteins

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Enzyme-Linked Receptors

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Mechanisms and Models of ErbB Receptor Signaling

Zhang et al Cell 2006

Peptide Moiety

ATP Moiety

EGFR Protein Kinase Structure Sordella et al Science 2004

EGFR

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Role of the activation Loopin RTK Regulation

20151021

Insulin receptor

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Role of the activation Loopin RTK Regulation

bull RTK contain between one and three tyrosines in the kinase activation loop

bull Autophosphorylation of activation loop tyrosinesndash Shown to be essential for simulation of catalytic

activity for RTKs bull Such as insulin receptor IGF1 receptor FGF receptor

Met Ros Nyk TrkA TrkB

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Role of the activation Loopin RTK Regulation

bull Phosphorylation of the activation loop stabilizes a conformationndash The active site is accessible to both substrates

MgATP and tyrosine-containing peptidendash Residues in the activation loop important for

catalysis (DFG sequence) and for peptide binding (end of the activation loop) are optimally positioned

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Regulation of Catalytic through Activation Loop Autophosphorylation

Autoinhibitory conformation of the unphosphorylated activation loop

Re-positioning of the activation loop upon autophosphorylation

The ATP analog the active site

substrate

The ATP analog the active site Mg2+ and the tyrosine-

containing [Y(P)] peptide substrate

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

PKA ERK2

PKA comparison with ERK2

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Structural Similarities Between Protein Kinases

Structure Function Relationship

But kinases maintain substrate selectivity

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Wang et al (1997) Proc Natl Acad Sci 94 2327-2332

Comparison of MAP kinase members(p38 MAPK and ERK2 structures)

p38 MAP kinase p38 MAP kinase and ERK2

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

MAP Kinase interactions with substrates

1 Proline directed kinases -consensus PXSTP site on substrates -minimum STP

2 Substrate domains a FXFP motif b D-domain - basic residues followed by an LXL motifc Kinase interaction motif (KIM) on phosphatases

3 Docking domains on MAP kinases (ERK and p38)Tanoue et al (2001) EMBO J 20466-479

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Mutants and over-expression

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

EGFR v-erbB

FS699

IV705

FS699

TK718HR811QL840SI932Δ1034Δ 1042-1062YN1091

EGF-R v-erbB-H v-erbB-ES4

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

腫瘤與血管增生

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Regulating MAP kinase function

a MAP kinases involved in cell proliferation and many other physiological responses

b Continuous activation is involved in disease

c Few MAP kinase inhibitors exist

d Most kinase inhibitors target ATP binding thus may lack selectivity Why

e Is it advantageous to selectively inhibit some but not all MAP kinase substrates

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Problem -MAP kinase (ERK) proteins phosphorylate and regulate dozens of substrates (~ 70)

How can one inhibit ERK substrates involved in disease but not normal metabolic processes

Hypothesis -Low MW compounds that bind unique MAP kinase docking domains can selectively inhibit interactions between the kinase and a specific substrate protein

Thus selective inhibition of phosphorylation and protein function

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

ERK

S3 S4

S1 S2

ATP ADP

pS1

pS4pS3

pS2

Cell proliferation

Substrate selective inhibition of ERK functions using small molecules

Test compound

ERK ERKS3 S4

S1 S2

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

2 Screen compounds based on ability to inhibit ERK-specific phosphorylation of substrate proteins and determine ERK binding interactions

3 Evaluate the effectiveness of biologically active compounds in inhibiting ERK-mediated cell proliferation

1 CADD database search of compounds that target ERK2 docking domains (need 3D structure)

Future Optimize lead compounds for selective inhibition of ERK substrates and in vivo studies

General CADD Research Design(for ERK2 inhibitors)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Example ERK2 CD and ED docking domains and computer aided drug design (CADD)

N-terminal

C-terminal

Molecular model of ERK2

ATP

substrate

Blue D316 and D319(common docking CD domain)Green T157 and T158(ED domain)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Herceptin Humanized Anti-HER2 Antibody

Targets HER2 oncoprotein

High affinity (Kd= 01 nM)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

HERCEPTIN History

Cloning ofEGFR cDNA

Relation toV-erbB

1984

Slamon et alScience

HER2 geneamplification

in Breast Cancerand correlation

with diseaseprogression

1987

1985

HER2Sequence published

Coussens et al

1989

Hudziak et alMCB

Anti-tumor effectOf MAb 4D5 and 2C4

Phase IRhu MAb

1992

1993

Phase II

Phase III

1995

ApprovalIn Europe

2000

1998

FDAApproval

2002

MAb 2C4In

Development

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

HERCEPTIN

bull Efficacy of Monotherapy in HER2neu +++ Patients Low (15)

bull Reminder Cancer is NOT a Monogenic Disease

bull Moving Disease Target due to Genetic Plasticity of Tumor Cells

bull Combination Therapy

HERCEPTIN +- Anthracyclines- Taxotere- Platinum Salts - etc

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Inhibitors of mammalian RTKs target different steps of receptor signaling cascades

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Terman et alBiochem Biophys Res Commun1992

Quinn et alProc Natl Acad Sci USA 1993

Millauer et alCell 1993

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Gene Therapy with Dominant-Negative VEGF-R Retrovirus

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Flk-1VEGFR2 Validation as Anti-Angiogenesis Drug Development Target

bull Receptor for VEGF

bull Specifically Expressed in Endothelial Cells

bull Essential for Tumor Angiogenesis

DEVELOPMENT OF SELECTIVE FLK-1 KINASE SMALL MOLECULE INHIBITORS

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

NH

O

NH

Chemical Structure of SU5416 -An Inhibitor of VEGF Receptor Kinase

SU5416 3-[2 4-dimethylpyrrol-5-yl methylidenyl]-2-indolinone

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

SU5 416 Response in AIDS Kaposirsquos Sarcoma

Protocol 5416003 Patient 003 R-P

Before treatment with SU5416 After treatment with SU5416

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Patient 018JZH SU5416 ResponseFacial Lesions

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

SU5416

bull Highly Selective

bull Efficacious in Mouse Models

bull Anti - Metastatic

bull Sub ndash Optimal Pharmacological Properties

bull Efficacious in Phase I Kaposi-Sarcoma Trial

bull Colon Cancer Trial Terminated

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Biochemical Effects of SU6668 a VEGFR-2 PDGFR amp FGFR RTK Inhibitor

SU5416SU6668

Flk-1Ki

PDGFR FGFR-1

Km (ATP) Ki Km (ATP) Ki Km (ATP)

01621

043043

0320008

6262

19512

2626

Mean Ki and Km values are shown (M)

EGFR

IC50

gt100gt100

NH

O

NH

NH

O

NH

SU5416 SU6668

bull Both compounds exhibit competitive (with respect to ATP) inhibition

bull Both compounds also inhibit ligand-dependent phosphorylation of c-Kit

NO

N

O

O

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

SU11248

An Oral Multi-Targeted Receptor Tyrosine Kinase Inhibitor with Anti-Tumor and

Anti-Angiogenic Activity

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

SU11248 A Multitargeted Kinase Inhibitor

Receptor Ligand Tumor Expression

PDGFR PDGF Glioma HCC NSCLC OvCa CaP melanoma CMML MDS

VEGFR VEGF CRC OvCa RCC Melanoma NSCLC Sarcomas Breast NET

KIT SCF GIST AML Melanoma SCLC Breast OvCa Cervix Mastocytoma

FLT3 FLT3 Ligand AML MDS T-ALL Neurological

Proliferation driven by mutant receptor

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

SU11248 Exhibits Cytoreductive Activity in Diverse Tumors of Patients in Phase I Clinical Trials

Phase I trials ongoing at multiple international sitesbull Patients heavily pre-treated with progressive disease at entrybull Confirmed partial responses observed

SU11248 is well toleratedbull most common toxicities seen in patients are fatigue GI and hematologic toxicity

Baseline Week 4

Patient with metastatic renal cell carcinoma腎臟癌

Eric Raymond et al 2002 NCIEORTCAACR

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

SU 11248SUTENT

August 2005Pfizer Submits a New Drug Application (NDA) to the

FDA for the Use of SUTENT in the Treatment of Gleevec-Resistant GIST

January 26 2006FDA approves SUTENT for treatment of Gleevec-

resistant GIST and RCCJuly 192006

EMEA Approval for Europe

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Sunitinib in metastatic RCC

Sunitinib is new first-line therapy in metastatic Clear Cell Renal Cell Carcinoma (RCC)

Adverse side effects are tolerable

Lung lesion response in RCC Courtesy of Dr Ronald Bukowski Cleveland Clinic Foundation

Before Treatment After 4 weeks of Sunitinib

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Sunitinib in Breast Cancer Patients

bull Open multicentric phase II study with 64 patients

bull Patients had been treated with chemotherapy that included at least an anthracycline or a taxanendash In average patients had received 35 different chemotherapiesndash 85 of patients had received adjuvant chemotherapy

bull Primary endpoint Response (RECIST)bull Secondary endpoints 1-year ndash survival duration of response tolerance

Miller et al ASCO 2005 Oral Presentation May 16

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Results

bull Sunitinib has significant efficacy when used as a monotherapy in patients with breast cancer

bull Partial response in 14 of patients (who had been treated before with various chemotherapeutic agents)

bull Moderate Side Effects

Miller et al ASCO 2005 Oral Presentation May 16

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

NH

OH

O

NH

O

NH

NH

ONH

NH

O

F

NH

N

O

SU6668 SU11248SU5416

From Mono- to Multi-Targeted Kinase Inhibitors

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

SUTENT History

Flk-1 shown to be VEGF-R(Millauer et al Quinn et al)

Dominant negative VEGFR-2Inhibits tumor angiogenesis and-grwoth in vivo(Millauer et al)

1993 1994 1999 2003 2006

SU5416 inhibits tumor growthIn vivo (Fong et al)

SU11248 orally activemulti-targeted drug (OlsquoFarrell et al)

SUTENT approval by FDAand EMEA (Pfizer)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Molecular Targets in Cancer

Receptor Tyrosine Kinase

RAS-GDP

RAF-1

SHC

BAD

SOSGRB-2

14-3-3

BCLXL

Mitochondria

BCLXL

SRC

P

STAT1+3

P

RAS-GTP

SAPK

P

AKT

14-3-3

BADP

RAS-GAPDOK

MYC

PI3K

MEK12P P

P

P

P

MAPK

mTOR

PSU11248 (Pfizer)

PZarnestra (JNJ)

PCT2584 (CTI)

PRAD001 (Novartis)CCI779 (Wyeth)

Rapamune (Wyeth)

PBAY43-9006 (Bayer)

Imatinib (Novartis)PBMS354825 (Bristol-MS)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Molecular-targeted agents under investigation in lung cancer

Phase I

Phase II

Phase III

Approved

GefitinibTarceva

AZD2171

Bortezomib

Vandetanib

Motesanib

SorafenibAvastin

Matuzumab

Cetuximab

Bexarotene

Imatinib

AZD6244

Tipifarnib

Talabostat

PF-3512676

Celecoxib

Sunitinib

AS1404

VEGF TRAP

Lapatinib

RAD001CP-751871

ABT-751

Vatalanib

Panitumumab

Angiogenesis inhibitorsEGFRHER

inhibitors

Other molecular-targeted therapies

HKI-272

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

bull Significantly Expand Cancer Mutation Database

bull Start with Cancer Kinome Analysis

bull Identify New Drugable Cancer Targets

bull Screening of Compound Librarys ndash Drug Discovery and Optimization

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Imatinib Bcr-Abl Novartis Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Erlotinib Erb1 GenentechRoche Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Lapatinib Erb1Erb2 GSK Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Vandetinib RETVEGFR AstraZeneca Small molecule

E7080 Multiple targets RETVEGFR

Esai Small molecule

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Name Target Company Class

Bevacizumab VEGF Genentech Monoclonal antibody

Ranibizumab VEGF Genentech Monoclonal antibody

Pegaptanib VEGF OSIPfizer Small molecule

AstraZeneca Small molecule

Small molecule

Sorafenib multiple targets OnyxBayer Small molecule

Dasatinib multiple targets BMS Small molecule

Sunitinib multiple targets Pfizer Small molecule

Trastuzumab Erb2 GenentechRoche Monoclonal antibody

Lapatinib Erb1Erb2 GSK Small molecule

Cetuximab Erb1 ImcloneBMS Monoclonal antibody

Erlotinib Erb1 GenentechRoche Small molecule

BIBW 2992 EGFR and Erb2 Boehringer Ingelheim Small molecule

Panitumumab EGFR Amgen Monoclonal antibody

Gefitinib EGFR AstraZeneca Small molecule

Imatinib Novartis Small molecule

Nilotinib Bcl-Abr Novartis Small molecule

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Cetuximab (IMC-C225 -- marketed under the name Erbitux) is a chimeric monoclonal antibody an epidermal growth factor receptor (EGFR) inhibitor given by intravenous injection for treatment of metastatic colorectal cancer and head and neck cancer Cetuximabwas discovered by ImClone Systems and is distributed in North America by ImClone and Bristol-Myers Squibb while in the rest of the world distribution is by Merck KGaA

an FDA approval of the drug in 2004 for useCetuximab is believed to operate by binding to the extracellular domain of the EGFR of all cells that express EGFR preventing ligand binding and activation of the receptor This blocks the downstream signaling of EGFR resulting in impaired cell growth and proliferation Cetuximab has also been shown to mediate antibody dependent cellular cytotoxicity (ADCC)Clinical uses[edit] Colorectal CancerCetuximab is used in metastatic colon cancer and is given concurrently with the chemotherapy drug irinotecan (Camptosar) a form of chemotherapy that blocks the effect of DNA topoisomerase I resulting in fatal damage to the DNA of affected cells While there remains some scientific controversy on this assessment for EGFR expression is required for use in Colorectal Cancer but not in Head amp Neck Cancer It is best to refer to updated Prescription Information[2]Head and neck cancerCetuximab was approved by the FDA in March 2006[3] for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients who have had prior platinum-based therapyOne of the side effects of Cetuximab therapy is the incidence of possibly severe acne-like rash

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Panitumumab (INN) also ABX-EGF is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor EGFR ErbB-1 and HER1 in humans)

FDA approved for the first time in September 2006EGFR is a transmembrane proteinPanitumumab works by binding to the extracellular domain of the EGFR (epidermal growth factor receptor) preventing its activation This in turn results in halting of the cascade of intracellular signals dependent on this receptor [2]

Panitumumab vs cetuximabAlthough they both target the EGFR panitumumab (IgG2) and cetuximab (IgG1) differ in their isotype and they might differ in their mechanism of action Monoclonal antibodies of the IgG1 isotype may activate the complement pathway and mediate ADCC (antibody-dependent cellular cytotoxicity) better than their IgG2 counterparts hence although they have not been documented differences in the responses in treatments with these two antibodies might be expected

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Gefitinib (INN) (originally coded ZD1839) is a drug used in the treatment of certain types of cancer Acting in a similar manner to erlotinib (marketed as Tarceva) gefitinibselectively targets the mutant proteins in malignant cells It is marketed by AstraZeneca and Teva under the trade name Iressa In 2004 AstraZeneca informed the United States Food and Drug Administration (FDA)

Gefitinib is the first selective inhibitor of epidermal growth factor receptors (EGFR) tyrosine kinase domain The target protein (EGFR) is also sometimes referred to as Her1 or ErbB-1 depending on the literature sourceEGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme Thus the function of the EGFR tyrosine kinase in activating the Ras signal transduction cascade is inhibited and malignant cells are inhibited

Gefitinib is currently only indicated for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) in patients who have previously received chemotherapy

Erlotinib is another EGFR tyrosine kinase inhibitor that works in the same way as gefitinib Given the lack of survival advantage for gefitinib and the positive results for erlotinib erlotinib has replaced gefitinib in the United States (except in patients where gefitinib has had a proven response)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

BIBW 2992 (trade name Tovok) is a candidate drug against non-small cell lung carcinoma developed by Boehringer Ingelheim As of May 2008 it is undergoing a Phase II clinical trialMethod of actionBIBW 2992 is a dual kinase inhibitor meaning it inhibits two receptors for growth factors (EGFR and HER2neu) Consequently it is directed against multi-resistant carcinomas with EGFR and HER2 mutations These occur mainly in women Eastern Asians and non-smokers

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Lapatinib (INN) or lapatinib ditosylate (USAN) (TykerbTyverb GSK) is an orally active chemotherapeutic drug treatment for solid tumours such as breast cancer[1] During development it was known as small molecule GW572016 Patients who meet specific indication criteria may be prescribed lapatinib as part of combination therapy for breast cancer[2] Pharmacologically lapatinib is a dual tyrosine kinase inhibitor that interrupts cancer-causing cellular signals[3] Lapatanib inhibits receptor signal processes by binding to the ATP-binding pocket of the EGFRHER2 protein kinase domain preventing self-phosphorylation and subsequent activation of the signal mechanism (see Receptor tyrosine kinaseSignal transduction)[5]

As of 2007 they have only progressed to Phase II trials[3]

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Trastuzumab (more commonly known under the trade name Herceptin) is a humanized monoclonal antibody that acts on the HER2neu (erbB2) receptor Trastuzumabs principal use is as an anti-cancer therapy in breast cancer in patients whose tumors over-express (that is produce more than the usual amount of) this receptor

The biotech company Genentech gained FDA approval for trastuzumab in September 1998Trastuzumab is a humanized monoclonal antibody which binds to the domain IV of the [4]extracellular segment of the HER2neu receptor Cells treated with trastuzumab undergo arrest during the G1 phase of the cell cycle so there is reduced proliferationThe initiation of trastuzumab therapy is based upon the identification of HER-2 overexpression

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Sorafenib (NexavarBayer) is a drug approved for the treatment of primary kidney cancer (advanced renal cell carcinoma) and advanced primary liver cancer (hepatocellular carcinoma)Sorafenib was approved by the US Food and Drug Administration (FDA) on December 20

2005 and received a EU marketing authorisation on July 19 2006[2]Sorafenib is a small molecular inhibitor of several protein kinases Protein kinases are overactive in many of the molecular pathways that cause cells to become cancerous These pathways include Raf kinase PDGF (platelet-derived growth factor) VEGF receptor 2 and 3 kinases and c Kit the receptor for Stem cell factor A growing number of drugs target most of these pathways Sorafenib is unique in targeting the RafMekErk pathway

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Dasatinib also known as BMS-354825 is a drug produced by Bristol-Myers Squibb and sold under the trade name Sprycel Dasatinib is an oral dual BCRABL and Src family tyrosine kinases inhibitor approved for use in patients with chronic myelogenous leukemia (CML) after imatinib treatment and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) It is also being assessed for use in metastatic melanoma黑色素瘤The main targets of Dasatinib are SRC Ephrins GFR In a Phase I dose escalation study published in June 2006 dasatinib was tested in patients who were resistant to or who could not tolerate imatinib (Talpaz et al 2006)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Sunitinib (marketed as Sutent and previously known as SU11248) is an oral small-molecule multi-targeted receptor tyrosine kinase (RTK) inhibitor that was approved by the FDA for the treatment of renal腎 cell carcinoma (RCC) and imatinib-resistant gastrointestinal stromal胃腸基質 tumor (GIST) on January 26 2006 Sunitinib was the first cancer drug simultaneously approved for two different indications [1] Sunitinib has become the standard of care for both of these cancers and is currently being studied for the treatment of many othersSunitinib inhibits cellular signaling by targeting multiple RTKs These include all platelet-derived growth factor receptors (PDGF-R) and vascular endothelial growth factor receptors (VEGF-R) which play a role in both tumor angiogenesis and tumor cell proliferation The simultaneous inhibition of these targets therefore leads to both reduced tumor vascularizationand cancer cell death and ultimately tumor shrinkage Sunitinib also inhibits KIT (CD117) the RTK that drives the majority of GISTs In addition sunitinib inhibits other RTKs including RET CSF-1R and flt3 [2]

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Bevacizumab (Avastin GenentechRoche) is a monoclonal antibody against vascular endothelial growth factor (VEGF) It is used in the treatment of cancer where it inhibits tumor growth by blocking the formation of new blood vessels (angiogenesis) Bevacizumab was the first clinically available angiogenesis inhibitor in the United StatesBevacizumab has been approved by the US Food and Drug Administration only for cancers that are metastatic (have spread to other parts of the body) although some doctors and patients want to use it for non-metastatic cancers In 2004 it was approved for combination use with standard chemotherapy for metastatic轉移性 colon結腸 cancer and non-small cell lung cancer[1] In 2008 it was approved by the FDA for use in breast cancer This was against the recommendation of its advisory panel[2] who objected because it only slowed tumor growth but didnt extend the patients life

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Ranibizumab (trade name Lucentis) is a monoclonal antibody fragment derived from the same parent murine antibody as bevacizumab (Avastin) It is much smaller than the parent molecule and has been affinity matured to provide stronger binding to VEGF-A It is an anti-angiogenic抗心絞痛 that has been approved to treat the ldquowetrdquo type of age-related macular 污點degeneration (ARMD) a common form of age-related vision lossRanibizumab was developed by Genentech and is marketed in the United States by Genentech and elsewhere by Novartis [1] under the brand name LucentisRanibizumab binds to and inhibits all subtypes of vascular endothelial growth factor A (VEGF-A) VEGF may trigger the growth of new vessels which may leak blood and fluid into the eye These leaky blood vessels may contribute to macular edema and choroidal neovascularization resulting in the wet type of ARMDBy blocking VEGF-A in the eye ranibizumab may prevent and reverse vision loss caused by wet macular degeneration

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Pegaptanib sodium injection (brand name Macugen) is an anti-angiogenic抗心絞痛medicine for the treatment of neovascular (wet) age-related macular degeneration老年性黃

斑部病變 (AMD) It was discovered by Gilead Sciences and licensed in 2000 to EyeTech Pharmaceuticals now OSI Pharmaceuticals for late stage development and marketing in the United States Outside the USA Macugen is marketed by Pfizer Approval was granted by the FDA in December 2004Pegaptanib is a pegylated anti-VEGF aptamer a single strand of nucleic acid that binds with specificity to a particular target Pegaptanib specifically binds to VEGF 165 a protein that plays a critical role in angiogenesis (the formation of new blood vessels) and increased permeability (leakage from blood vessels) two of the primary pathological processes responsible for the vision loss associated with neovascular AMD

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

httpwwwreactionbiologycompageskinasehtm

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

Targeting VEGFThe Bevacizumab Story

PP

PP

VEGFBevacizumab

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

VEGFBevacizumab

PP

PP

VEGF Activation BLOCKED

Targeting VEGFThe Bevacizumab Story

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)

藥 品 詳 細 資 料學名 Paclitaxel

藥商 藥價 30 mg vial = NT 4104 ~ 4396商品英文名稱 Taxol商品中文名稱 汰癌勝 (太平洋紫杉醇)

劑型 靜脈注射劑

藥理作用

1 紫杉醇屬有絲分裂 中的微小管抑制劑紫杉醇具有聚合和穩定細胞內微管的作用致使快速分裂的腫瘤細胞在有絲分裂階段被牢牢固定使微小管不再分開使癌細胞複製受阻斷而死亡 和目前常用的化療藥作用機理不同2 紫杉醇屬有絲分裂中的微小管抑制劑可阻斷細胞於細胞周期之G2與M期3 此藥在由 Cytochrome P-450 isozymes 肝臟代謝嚴重肝功能異常病人降低劑量是合理的

常用劑量

1劑量按 175~200 mgM2 體表面積計算3~4 小時靜脈滴注 (最好使用靜脈 Pump)每3週1次用藥量和用藥次數可酌情增減[註] 不能用於中性白細胞計數少於1500個mm3的患者的治療因此對用藥患者應經常進行白細胞計數用藥量和用藥次數可酌情增減2 當與 CDDP 併用必須先給 Paclitaxel因為相反的次序造更大的毒性

衛生署許可證適應症 晚期或無法手術切除之非小細胞肺癌

健保藥品給付規定

晚期或無法手術切除之非小細胞肺癌

藥 品 詳 細 資 料

副作用

Taxol 所產生之副作用中骨髓抑制過敏反應心律不整及神經毒性作用等較具有臨床上之重要性且為主要限制 Taxol 繼續調昇劑量的因素1 Taxol所造成周邊神經毒性和劑量有關且主要發生在當劑量大於 250mgM2時bull常見為手套和襪樣麻木( glove-stocking numbness)和感覺神經異常的毒性反應 (60) 2 可能發生輕度到中度噁心嘔吐腹瀉少數肝功能指數上升3 輕度到中度的皮膚過敏4 對骨髓的抑制反應和劑量有關常見白血球減少 (gt 80)但對血小板紅血球的影響較小bull白血球減少常發生於使用後 8~11天而於 15~21天恢復5 禿髮是顯而易見的副作用發生在第二或三療程 後這過程是可逆的只要停止治療後 4~ 6週後可能再生6 免疫bull大約 40 與抗組織胺有關的過敏反應bull嚴重而且威脅生命的急性過敏性休克發生 很罕見bull輸注時間太短較容易見到過敏反應7 心室心律不整無症狀的心搏過緩少數傳導阻滯有30可以見到 EKG 變化 (第一次注射 Taxol 藥監測心律)8 肌肉痛和關節痛發生在開始治療的前幾天

備註

1 為防止病人發生過敏反應接受本品的所有病人應事先給予預防用藥bull通常在給藥前30分鐘(or 後)分別口服 或靜脈注射皮質類固醇 ( Dexamethasone 8mg BID D-1 D0 D+1 ) bull抗組織胺 Diphenhydramine 50mg bull 抗潰瘍藥 Cimetidine 300mg IV (or Ranitidine 50 mg IV) 2 使用前將本品稀釋 生理食鹽水或5葡萄糖注射液500ml中用非聚氯乙烯(non-PVC) 材料的輸液瓶和輸液管靜脈滴注3 建議當合併 Taxol 與 Cisplatin 之治療時Taxol需在Cisplatin 之前給藥 (由於Cisplatin可能影響Taxol的血漿清除率)