Targeting growth factors and angiogenesis; using small molecules in malignancy

Cancer Metastasis Rev (2006) 25:279–292

DOI 10.1007/s10555-006-8508-2

Targeting growth factors and angiogenesis; using small moleculesin malignancy∗

Harold J. Wanebo · Athanassios Argiris ·Emily Bergsland · Sanjiv Agarwala · Hope Rugo

C© Springer Science + Business Media, LLC 2006

Abstract Targeted biologic therapy for cancer has evolved

from the laboratory to active clinical protocols and ap-

plied clinical practice in selected patients. Major targets

include epidermal growth factor, and vascular endothelial

growth factor receptors which are commonly expressed in

gastro-intestinal cancers head & neck and lung cancers,

and to some degree breast and gynecologic malignancy.

Down stream signal transduction pathway inhibition of B-

raf and N-ras mutations are examined in melanoma. New ap-

proaches involving re-packaging of chemotherapeutic agents

are being exemplified in the nanoparticle formulation of

prclitaxel which provides increased access to endothelial

and tumor cells with potential enhanced therapeutic effi-

∗Presented as a lunch mini-symposium at the First InternationalSymposium on Cancer Metastasis and the Lymphovascular System.April 28–30, 2005, San Fransciso, CA; Chaired by Harold J.Wanebo.

H. J. Wanebo ( (�) overview)Department of Surgery, Division Surgical Oncology, RogerWilliams Medical Center, Providence, RI, USAe-mail: [email protected]

A. Argiris (Anti EQER Therapy)Department of Medicine, Division of Hematology/Oncology,University of Pittsburgh, Pittsburgh, PA, USA

E. Bergsland (Anti Angiogenesis)Department of Medicine, University of California, SanFranscisco, CA, USA

S. Agarwala (B-ref and Melanoma)Division of Hematology Oncology, University of Pittsburgh,Pittsburgh, PA, USA

H. Rugo (Nano particle Paclitaxel)Department of Medicine, Carol Franc Buck Breast Cancer Center,University of California, San Francisco, CA, USA

cacy compared to the conventional version solubilized in a

cremophor.

Keywords Oncologic targeting · Growth factors ·Angiogenesis · Small molecules

Introduction

In recent years the concept of targeted biology therapy has

evolved from the pre-clinical laboratory models to active

clinical protocols and developmental clinical programs. Two

major biologic targets include: the epidermal growth fac-

tor receptors (EGFR) and angiogenesis, vascular endothelial

growth factor inhibitors (VEGF). Well defined inhibitors in-

clude antibodies to the receptor or tyrosine kinase inhibitors.

Although these agents may demonstrate 5–10% clinical

response in selected patient populations, the optimum effects

occur when used in combination with active chemotherapy

regimens. Significant enhancement of chemotherapy and ra-

diation therapy responses by EGFR and VEGF have been

documented in head and neck squamous cancer, lung cancer,

and selected gastro intestinal cancers (metastatic colorectal

cancers). Targeting of these two major growth factor sys-

tems has been a common theme of many clinical trials at this

time.

Other small molecules include cell cycle inhibitors

(flavoperidol), oncogene antagonists, i.e. against mutated

P53, (Onyx), disease specific mutations, i.e. Ph chromosome

in chronic myelogenous leukemia (CML), C kit receptor in

GIST (gastro intestinal stromal tumors) targeted specifically

by Gleevec.

The signal transduction pathway provides a myriad of

targets, i.e. ras, BCL-2, and many other factors, which

potentiate tumor cell growth. The Braf pathway plays a major

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280 Cancer Metastasis Rev (2006) 25:279–292

role in the development of melanoma, and is now the focus

of study in RAF kinase inhibitors which may have an im-

portant therapeutic role. Lastly the need for optimum formu-

lation of cytotoxic and biologic anti-tumor agents is critical

for adequate delivery of these agents to the tumor. Recent

formulation of Taxanes using albumin via nanotechnology

can provide drugs with greater ability to concentrate at much

higher levels in tumor tissue vs. normal tissue (increasing the

therapeutic index of the drug).

The overall panel should provide exciting information

on the evolving biologic treatment strategy for cancer.

Because of space limitations the manuscripts are meant

to provide a reasonable clinically focused rather than a

comprehensive sketch of each area. Selected references

should provide a good entre to the field, each of the

areas.

Anti EGFR therapy for malignancy

Epidermal Growth Factor Receptor (EGFR) is a member of

the EGFR family of receptors (or ErbB tyrosine kinase re-

ceptors) that is critical for the growth of many epithelial ma-

lignancies. After ligand binding, EGFR dimerizes with other

EGFR subfamily receptors, such as HER2, and activates a

signaling cascade that results in tumor proliferation, angio-

genesis, survival, and invasion/metastasis [1]. Multiple stud-

ies have demonstrated that EGFR is commonly expressed in

epithelial malignancies and its high expression usually cor-

relates with worse patient outcome [2]. On the basis of a

strong biologic rationale, EGFR emerged as a promising tar-

get for anticancer therapy [1]. The two main ways for target-

ing this important molecule are with EGFR tyrosine kinase

inhibitors (EGFR-TKIs) that block the ATP binding site in

the cytoplasm, such as erlotinib and gefitinib, and with mono-

clonal antibodies against the extracellular ligand binding do-

main of the receptor, such as cetuximab [3]. In recent years,

EGFR inhibitors were introduced in the standard manage-

ment of many solid tumors. Currently, in the United States,

three EGFR inhibitors have obtained regulatory approval:

gefitinib and erlotinib for the treatment of previously treated,

advanced non-small cell lung cancer (NSCLC) and cetux-

imab for irinotecan-refractory colorectal cancer. Erlotinib

was approved on the basis of survival benefit demonstrated

in a phase III clinical trial, whereas gefitinib and cetuximab

were approved on the basis of antitumor activity observed

in phase II trials. Phase III data with the use of the above

agents are being accumulated, whereas multiple other agents

that target the EGFR pathway are under development (see

Table 1). We will summarize the current status of clinical

studies with EGFR inhibitors in four common malignancies:

NSCLC, head and neck cancer, pancreatic cancer, and col-

orectal cancer.

Non-small cell lung cancer

In phase II trials, gefitinib and erlotinib have resulted in

responses of 10–20% in patients with previously treated,

advanced NSCLC [4–6]. Phase III randomized trials that

compared an EGFR-TKI with placebo in patients with

NSCLC recently reported results. In one of these stud-

ies, erlotinib prolonged median survival by approximately

2 months compared with placebo in previously treated pa-

tients with advanced NSCLC, a difference that was statisti-

cally significant [7]. However, gefitinib, in a similar clinical

setting, did not result in significant survival improvement

when compared with placebo, even though survival benefit

was seen in certain patient subgroups, such as the Asians and

nonsmokers [8]. This led the United states FDA to restrict

the approved use of gefitinib to patients with NSCLC who

have already received and benefited from the drug. Moreover,

EGFR-TKIs failed to improve patient outcome when added

to standard first-line chemotherapy for advanced NSCLC [9,

10]. It is likely that the negative results that emerged in some

of the phase III studies with EGFR-TKIs were due to the

lack of appropriate patient selection on the basis of clinical

characteristics or molecular markers.

Cetuximab has also been studied in NSCLC, as single-

agent and in combination with chemotherapy, in phase II

trials [11, 12]. Based on promising results, ongoing phase III

randomized trials are evaluating the addition of cetuximab to

chemotherapy for the first-line as well as of the second-line

therapy of advanced NSCLC.

Head and neck cancer

Head and neck carcinomas are EGFR-dependent neoplasms.

Cetuximab has been extensively studied for the treatment

of squamous cell carcinoma of the head and neck. A recent

phase III randomized trial demonstrated that the addition of

cetuximab to radiation improves locoregional control and

survival compared with radiation alone in patients with lo-

cally advanced head and neck cancer [13]. The magnitude

of survival improvement at 3 years (approximately 13%) is

comparable to what is achieved with the addition of cisplatin

to radiation. In recurrent or metastatic head and neck cancer,

the addition of cetuximab to cisplatin did not significantly

prolong progression-free survival in a randomized trial con-

ducted by the Eastern cooperative Oncology Group (ECOG

5397); the survival increased only from 3.4 months to 4.1

months [14]. Nevertheless, the objective response rate more

than doubled in the cetuximab arm, from 9% to 23%. More-

over, cetuximab was recently shown to have single-agent ac-

tivity in head and neck cancer. A phase II trial that enrolled

103 patients with platinum-refractory recurrent or metastatic

head and neck cancer, reported an objective response rate of

13%, median time to progression of 2.3 months, and median

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Cancer Metastasis Rev (2006) 25:279–292 281

Table 1 Selected anti-EGFR agents for cancer therapy

Agent Type of inhibitor Status Manufacturer

Monoclonal

antibodies

Cetuximab Chimeric antibody Approved in colorectal cancer. Positive BMS/ImClone

(Erbitux, C225) phase III trial in head and neck cancer.

Phase III studies ongoing in non-small cell

lung cancer and pancreatic cancer

Panitumumab Human antibody Phase II in NSCLC, colorectal, and others Amgen

(ABX-EGF)

Matuzumab Humanized antibody Phase II in NSCLC, colorectal, head and neck EMD

(EMD 72000) cancer, cervical, gastric, and ovarian cancers Pharmaceuticals

Tyrosine

kinase

inhibitors

Gefitinib Aniloquinazoline; Approved in NSCLC but negative data AstraZeneca

(Iressa, ZD1839) reversible emerged in phase III trials ongoing Phase III

trials in head and neck cancer. Phase II

in other cancers.

Erlotinib Aniloquinazoline; Approved in NSCLC. Positive phase III in Genentech/OSI

(Tarceva, OSI-774) reversible pancreatic cancer. Phase II in other tumor

types.

EKB-569 3-cyanoquinoline; Phase II in colorectal cancer Wyeth-Ayerst

Lapatinib ditosylate irreversible

(GW572016) Dual EGFR and Phase III trial in breast; phase II trials in head GlaxoSmithKline

HER2 inhibitor; reversible and neck, lung, and others

survival of 5.9 months [15]. Notably, there was no statis-

tically significant correlation between response and EGFR

expression.

The EGFR-TKIs, gefitinib and erlotinib, have modest sin-

gle agent activity (3–11%) in recurrent, metastatic head and

neck cancer [16–18]. An ongoing phase III trial is comparing

docetaxel with or without gefitinib in patients with recurrent

or metastatic squamous cell carcinoma of the head and neck

(ECOG 1302).

Pancreatic cancer

EGFR inhibitors are the first novel agents to show promise in

pancreatic cancer. A recent phase III randomized trial showed

that the addition of erlotinib to gemcitabine resulted in a

small but statistically significant survival benefit in advanced

pancreatic cancer [19]. A phase III trial of gemcitabine with

or without cetuximab is currently ongoing (SWOG 0205).

Colorectal cancer

Cetuximab has single agent activity in irinotecan-refractory,

advanced colorectal cancer; a phase II trial reported an ob-

jective response rate of 9% [20]. A randomized phase II trial

evaluated the combination of cetuximab and irinotecan and

cetuximab alone in irinotecan-refractory patients [21]. The

combination was proven to be clearly superior in terms of

response rates and progression-free survival. This study con-

firmed previous clinical and laboratory observations that the

addition of cetuximab to irinotecan reverses irinotecan re-

fractoriness. Accelerated approval of cetuximab by the FDA

was based on the above studies. Currently, phase III trials of

cetuximab plus chemotherapy for the treatment of advanced

colorectal cancer are ongoing. Although studies in colorectal

studies (as well as in most NSCLC studies) required EGFR

tumor positivity, cetuximab may be equally active in EGFR

negative tumors [22]. This remains to be evaluated prospec-

tively in clinical trials. The EGFR-TKIs are also under study

in colorectal cancer [23].

Molecular markers

Surprisingly, reliable molecular biomarkers to predict bene-

fit from EGFR targeted therapy have been elusive. This field

has rapidly evolved in the past year. In 2004, function-gaining

mutations in EGFR were identified that lead to exceptional

clinical responses to the EGFR TKIs in NSCLC [24]. How-

ever, these mutations are present in a relatively small fraction

of NSCLC patients (only 10% in Caucasians but may exceed

50% in East Asians) and can only partially account for the

demonstrated clinical benefit from these agents. EGFR muta-

tions seem to be very rare in other tumor types. EGFR gene

copy number is emerging as another predictor of EGFR-

TKI activity in NSCLC [25] and cetuximab in colorectal

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Table 2 Small-molecule inhibitors of VEGFR tyrosine kinases in clinical development

Product Target Clinical Tumor type Company

SU5416 VEGFR-1, -2 Phase III development Solid tumors, CRC, Sugen/Pfizer

discontinued melanoma

SU112248 VEGFR PDGFR-β Phase II Solid tumors, GIST, RCC Sugen/Pfizer

SU6668 VEGFR-2 Phase I Solid tumors Sugen/Pfizer

PDGFR- β bFGFR

PTK/ZK VEGFR-1, -2 -3 c-KIT Phase III Solid tumors, CRC, GBM, Schering AG/Novartis

RCC, mesothelioma

ZD6474 VEGFR-2/EGFR Phase II Solid tumors, NSCLC, AstraZeneca

SCLC

CEP-7055 VEGFR-1, -2, -3 Phase I Cephalon

CP-547, 632 VEGFR-2, EGFR,PDGFR Phase I Pfizer

AG013736 VEGFR Phase I Pfizer

GW786034 VEGFR-2 Phase I GlaxoSmithkline

AEE788 VEGFR/EGFR Novartis

AMG706 VEGFR-1, -2, -3 Phase I Solid tumors, CRC Amgen

bFGFR = basic fibroblast growth factor; CRC = colorectal cancer; EGFR = epidermal growth factor receptor; GBM = glioblastoma multiforme;GIST = gastrointestinal stromal tumor; NSCLC = non-small cell lung cancer; PDGFR = platelet-derived growth factor receptor; RCC = renalcell carcinoma; SCLC = small cell lung cancer; VEGFR = vascular endothelial growth factor receptor.

cancer [26]. On the other hand, K-ras mutations may predict

for resistance to EGFR-TKIs [27]. Downstream molecular

markers in the EGFR signaling pathway, such as AKT, are

also being evaluated as potential predictors of outcome [28].

Of interest is that the development of rash, a class effect of

the EGFR inhibitors, has been shown to correlate with pa-

tient outcome [29]. An intriguing hypothesis is that the de-

velopment of rash with EGFR inhibitors is associated with

CA-repeat polymorphisms in intron 1 of the EGFR gene[30].

Further translational research is needed to identify the ap-

propriate subset of patients that benefit the most from EGFR

blockade. Combinations of EGFR inhibitors with other novel

agents, such as angiogenesis inhibitors are being pursued as

well. The role of EGFR-targeted agents for cancer therapy is

expected to expand in the future.

Anti angiogenesis development therapy in malignantdisease

Blood vessels and lymphatics depends on members of the

VEGF Protein family [31]. VEGF-A, VEGF-B, VEGF-C,

VEGF-D, VEGF-E and placental growth factor (PGF) bind

to specific receptor tyrosine kinases, activating the signal

transduction that directs cellular functions. VEFG-A, the

best characterized of VEGF family is the most potent di-

rect acting Angiogenenic protein [32] and is essential for

vasculo-genesis and angiogenesis [33]. VEGF production in

tumor cells may be initiated by mutation in tumor cells gov-

erning growth regulation pathway, or by the hypoxic micro

environment of the tumor (hypoxia inducing factor) or by

stimulation by other growth factors, epidermal growth fac-

tor (EGF), platelet derived growth factor (PEGF), insulin

like growth factor (IGF), stress and other factors [34–36]. A

number of strategies have been developed to inhibit VEGF

(Fig. 1, Table 2).

Antibodies and soluble VEGF receptors bind to the VEGF

ligand and prevent its binding to the VEGF receptor thus in-

hibiting the proangiogenic VEGF cascade [37]. These agents

may also bind to the VEGF receptor. Bevacizumab is the best

characterized of the anti-VEGF monoclonal antibodies [37,

38]. It is a humanized variant of monoclonal antibody (93%

human, 7% mouse) that binds to VEGF with high affinity and

neutralizes all VEGF-A isoforms. It is the first anti angio-

genic compound to receive FDA approval (February 2004)

for first line treatment of patients with Metastatic Colorectal

Cancer.

Bevacizumab (5 mg/kg every 2 wks.) was added to

IFL which included weekly administration of irinotecan

at 125 mg/M2, bolus 5FU at 500 mg/M2, and leucovorin

200 mg/M2 in patients with previously untreated Metastas-

tic Colorectal Cancer (Table 3). A third arm Bevacizumab

5FU/Leucorvovin was closed once safety of the Bev and IFL

was established. The median survival was improved in the

IFL/Bevacizumab group vs. the IFL and placebo (20.3 mos

vs. 15.6 mos.), P0.0001 corresponding to a 34% reduction

in risk of death (Table 3) [39, 40]. Other improvements were

shown in progression free survival, median duration of re-

sponse and response rate. An increased number of adverse

Bevacizumab associated events (approximately 10% over-

all increase) occurred as manifested by hypertension (11%

with Bev. vs. 2.3% with placebo). P < 01 and an increase

in perforation (6 of 393 patients, 1.5%). The role of Beva-

cizumab in 2nd line was examined by ECOG (Eastern Coop-

erative Oncology Group) which randomized 789 patients to

3 treatment arms involving: FolFox biweekly (Oxaliplatin,

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Table 3 Bevacizumab plusirinotecan (Ir), fluorouracil (5fu)and leucovorin (lv) as first linetreatment for metastaticcolorectal cancer

IFL plus Bevacizumab IFL plus placebo

(n = 402)∗ (n = 411) P value

Median survival (months) 20.3 15.6 < 0.001

Progression-free survival (months) 10.6 6.2 < 0.001

Response rate (%) 44.8 34.8 0.004

Median duration of response (months) 10.4 7.1 0.001

1. Hurwitz et al. New Engl. V. Med 2004:350,2335–2342.2. Kabbinavar FF et al. J. Clin Oncol. 2005, 23:3697-3705 (an update)∗Bev-5 mg/mg 2 wks

Ir-125 mg/mg q wk5fu-500 mg/mg q wk

lv-20 mg/mg q wk

Fig. 1 Mechanistic approachesto VEGF inhibition

85 mg/M2 vs. 5FU 400 mg/M2 IV bolus followed by CI 5FU

600 mg/M2) (Table 4). The trial included FolFox alone, Fol-

Fox with high dose Bevacizumab, and Bevacizumab alone 10

mg/M2 in patients with previously treated colorectal cancer

patients [41]. These pts had previously failed 5FU/ Irinotecan

chemo therapy. Bevacizumab was relatively inactive as single

agent, but significantly augmented survival when combined

with FolFox vs FolFox alone (from 10.7 mos. to 12.5 mos.)

P0 < 0.002. It also significantly increased progression free

survival (from 5.5 to 7.4 months) and response rate (9.2% to

21.8%) P < 000.1. Toxicity was generally tolerated although

Bevacizumab was associated with increase in perforation and

hemorrhage (73%).

Bevacizumab has been combined with an (EGFR In-

hibitor) in irinotecan refractory pts in a Medical Council Re-

search Study (Bond study) (Table 5). This small trial involved

81 pts of whom 85% had failed Oxaliplatin. Patients were ran-

domized to Bev. 5 mg/M2 at 2 wks and Cetuximab (400 mg

loading dose and 250 mg/M2 weekly) with/without irinote-

can. There was an improved overall response rate of 37% vs.

20%, and increased time to disease progression 7.9 months

vs. 5.6 months (P < 01 in the Bev/Cetux/Irinotecan group vs.

Bev/Cetux [21, 42]. In comparison to a previous historic data

from the study, the combination Cetux/Bev/Irinotecan was

superior to Cetuximab/Irinotecan in response rate (37% vs.

23%) and time to progress (7.9 months vs. 4 months). This

suggests that the combination of EGFR and VEGF mono-

clonal antibody inhibitors may be of benefit [43].

Bevacizumab has also been examined in NSCLC (ECOG

4599) [44, 45]. Patients with stage III B or IV squamous

NSLC were randomized to receive paclitaxel (P) 200 mg/M2

and Carboplatin (C) at AUC of 6 mg/M2 min every 3 weeks

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Table 4 High doseBevacizumab plus FOLFOX vs.Placebo plus FOLFOX vs.Bevacizumab as second linetreatment in metastaticcolorectal patients previouslytreated and refractory toSFU/irinotecan

A: FOLFOX plus∗

Bevacizumab B: FOLFOX plus C: Bevacizumab

(n = 282) Placebo (n = 279) (n = 243)

Median survival (months) 12.5∗ 10.7 10.2

Progression-free survival (months) 7.4† 5.5 3.5

Response rate (%) 21.8‡ 9.2 NA

Median duration of response (months) NA NA NA

Giantonio, B.J., 2005 ASCO Presentation; Ab 2.∗Bev.-10 mg/kg q 2 wksFOLFOX 4Oxaliplatin 85 mg/M2

5 Fluorouracil 400 mg/M2 I.V. bolusFollowed by 5FU 600 mg/M2 C.I.Leucovorin 200 mg/M2

AvsB; ∗p2 0.0024; †p = 0.0001, ‡p = 0.0001, NA (Not available)

Table 5 Efficacy ofbevacizumab and cetuximab inirinotecan-refractory patientswith metastatic colorectalcancer (Bond 2 study), andcomparison with results fromthe BOND 1 study

BOND 1 BOND 2

Cetuximab/irinotecan Cetuximab/bevacizumab/

(historical) irinotecan N = 41 P value

RR (%) 23 37 0.03

TTP (months) 4 7.9 < 0.01

Cetuximab alone Cetuximab/bevacizumab P value

(historical) N = 40

RR (%) 11 20 0.05

TTP (months) 1.5 5.6 < 0.01

Saltz L, et al. ASCO 2005

Bond 1: Cunningham et al. NEJM 2004:351:337–345.Bond 2: Saltz, et al. Proc ASCO:2005, Ab3508.Above summarized by Kabbinavar F., ASCO presentation, 2005.

vs. the combination plus bevacizumab every 3 weeks up to

6 cycles (after which patients would continue bevacizumab

until progression or if not tolerated. Overall survival was

improved 12.5 months in the P. C. Bev arm vs. 10.2 months

with PC alone P0.0075.

There was improvement in the response rate (27% vs.

10%) and time to progression 6.4 vs. 4.5 months, P.0001.

The P.C. Bev group had a higher complication rate vs. P.C.

alone. The toxicity profile included, neutropenia 24% vs.

16%, hemorrhage (4.5% vs. 0.7%, hypertension 6% vs. 0.7%,

p < 001 for each event). Nine of 11 treatment related deaths

occurred in PCB group (5 were related to hemoptysis). Thus

there is clinical benefit, but at increased toxicity [46] with

combination Bev. and Chemotherapy.

Other VEGF inhibitors include VEGF trap [47–49] and

VEGF Tyrosine kinase inhibitors which can block the signal-

ing cascade directed by the tyrosine catalytic site following

its activation by VEGF-VFGF receptor interaction (Table 1)

[50–58]. These signals normally lead to activation of variety

of processes, such as endothelial cell proliferation migration,

cell survival, vascular permeability, and proliferation of cells

directed to promoting angiogenesis. A variety of the tyrosine

kinase inhibitors are listed in Table 1.

Targeting the signal transduction pathway inmelanoma

The RAS Pathway is an important signal cascade in

melanoma (Fig. 2) [59–63]. RAS mutations include N-Ras

mutations which occur in about 15% and B-Raf mutations

which occur in 60–70% of melanomas (Table 6). The NRAS

and BRAF mutations appear to be mutually exclusive. Over-

all 7% of cancers have the BRAF mutation including 30–70%

of melanomas and 30–50% of hepatobiliary and thyroid

cancers. Mutations are found in over 60% of melanoma

metastases, and in 60–80% of melanoma cell lines and cul-

tures. The V600E B-Raf occurs in approximately 50% of

melanomas [64] V600E B-Raf is a thymidine to adenosine

(valine glutamic acid) mutation and is one of the most ac-

tive mutants whose invitro kinase actively is >500x that of

wild type B-Raf. Type V600E B-Raf induces proliferation

and transformation. B-Raf activation occurs early in tumor-

genesis, but by itself doesn’t induce cancer V600E B-Raf

and (NRAS) are also found in a high proportion of nevi and

thus appear associated with initiation rather than progres-

sion [65, 66]. The B-Raf incidence varies among the differ-

ent types of melanoma, ranging from 35-70% in cutaneous

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Fig. 2 B-Raf and N-RafMutative in Melanoma

Table 6 BRAF and melanoma (a brief summary)

• Incidence of BRAF does not correlate with thickness.

• Presence of BRAF mutation does not alter survival.

• Higher frequency in patients < 60 years old.

• Conflicting results in patients with stage IV in terms of overall survival based upon BRAF mutation status.

• Very few melanomas acquire mutations in BRAF in later stages, so specific mutation persists from primary to metastases.

• Majority of BRAF mutation are somatic. Not a melanoma susceptibility gene.

• V 600E B-RAF is one of the most active mutants.

• In vitro kinase activity approx. 500 fold greater than wild type B-RAF.

• Braf is on oncogene- V 600E B-RAF induces proliferation and transformation.

• However, V 600E B-RAF (and NRAS) are detected in a high proportion of nevi.

• BRAF activation occurs early in tumorigenesis and by itself it is not sufficient to induce cancer.

• Associated with initiation rather than progression.

melanoma, <10% in mucosal, 0% in uveal and 14–20% in

conjunctival melanomas (Summarized in Tables 1, 2) [67–

69]. There is also a range of B-Raf expression in differ-

ent types of cutaneous melanoma ranging from 54% in su-

perficial spreading, 20–50% in nodular melanoma, 15–33%

in acral lentiginous melanoma and < 8% in lentiginous

melanoma (Table 7) [62, 67].

The incidence of B-Raf doesn’t correlate with thickness

and it doesn’t relate to survival. The specific BRAF mutation

persists from its occurrence in the primary lesion to its pres-

ence in metastastic melanoma (Overall data summarized in

Table 1) [63]. The majority of BRAF mutations are somatic

not genetic.

BAY-43-9006 is a bis-aryl urea that was discovered in

a screen for C-RAF inhibitors [70]. Hypothesis generating

studies have been based on targeting B-Raf with RAF Kinase

inhibitors such as (BAY-43-9006) in melanoma at various

stages. BAY-43-9006, inhibits the RAF/MEK/ERK Cascade,

inhibiting RAF dependent cellular proliferation [71, 72]. The

inhibition required for IC50 ranges from 2nM – with Bay-

43-9006 to 6–10 nM with, VEGFR2, VEGFR3, inhibitors to

20–40 mm with wild type W+B-RAF, V599E B-RAF.

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Table 7 BRAF mutations associated with melanoma

Type of melanoma Incidence of mutation

– Cutaneous 35–70%

– Mucosal 0–10%

– Uveal 0%

– Conjunctival 14–23%

– SSM 54%

– Nodular 20–50% (?)

– LMM 0–8%

– Acral/Lentiginous 15%–33%

– Desmoplastic 0% (0/12)

Options for therapy

an initial study of BAY-43-9006 – was done in a small series

of 39 patients with metastastic melanoma and showed limited

efficacy of the drug as a single agent (5% Response Rate).

There was 1 response in a patient with regional metastases

and less than 20% had stable disease at 12 weeks [73, 74].

There was also a Phase I/II Study of BAY 43-9006 combined

with carboplatin and paclitaxel study in failed patients, with

progressive metastatic melanoma [75]. Partial Response oc-

curred in 20 (30%) of 54 patients, 1 had Stable Disease and

26 (48%), of the patients showed no change. Progressive

disease occurred in 5 patients (9%) and the protocol was dis-

continued in 3 pts (6%). Currently there is a new Protocol

conducted by ECOG (Eastern Cooperative Oncology Group)

E2603 in patients with metastatic melanoma: this consists of

thrice weekly Paclitaxel 225 mg/M2, Carboplatin AUC6 ±BAY 43-9006 400 g PO-BID. Tissue blocks will be available

to characterize the relation between BRAF and the RAS Cas-

cade, mutational status and response. The initial preliminary

response data is noted in Table 8.

Conclusion

The demonstration of the BRAF pathway in melanoma and

the study of one of its inhibitors, BAY 43-9006 are examples

of a new era of treating a formidable disease with targeted

therapy. Further studies will hopefully build on the ECOG

study and the data from other groups to determine the true

value of blocking this unique pathway in melanoma.

Nanoparticle drug formulations to enhanceanti-tumor therapy nab-paclitaxel: Teaching an olddog new tricks?

Taxanes represent a highly potent class of chemotherapeu-

tic agents for the treatment of a variety of solid tumor

malignancies. In breast cancer, the use of taxanes has

changed therapeutic options in both the metastatic and adju-

vant settings. Rationale combinations of taxanes with other

chemotherapeutic agents have been tested in metastatic dis-

ease, and are now under study as treatment for early stage

breast cancer to improve outcome. Genomic and expression

analyses in the neoadjuvant as well as metastatic settings have

begun to evaluate specific factors that correlate with appar-

ent sensitivity or resistance to taxanes. A new formulation of

paclitaxel that avoids the use of Cremaphor and capitalizes

on the natural biology of tumor vasculature and tumor cells

for potential targeting, nab-paclitaxel, was FDA approved

for the treatment of metastatic breast cancer in January of

2005. Agents given by the intravenous route need access to

the vasculature, and from the interstitum into the tumor cell.

Ideally, effective chemotherapy agents would be targeted, so

that the concentration of active agent would be higher in the

tumor cell than in normal tissue. Pre-clinical data suggests

that nab-paclitaxel may function at least in part by targeting

to both endothelial and tumor cells. Glycoprotein-60 is an

albumin receptor on the surface of endothelial cells that is

involved with transportation of albumin across the endothe-

lial cell membrane through a protein named calveolin. An-

other receptor, SPARC, appears to play an important role in

the transport of albumin into tumor cells. Both caveolin and

SPARC are found in increased levels in a variety of malig-

nances. This possible targeting of chemotherapeutic agents

using an albumin modified via nanotechnology may allow

the exploitation of a natural system to enhance treatment ef-

ficacy.

Metastatic breast cancer is generally incurable with only

a few patients achieving long-term survival with standard

chemotherapy [76]. Despite a marked increase in the choice

of active agents for the treatment of metastatic disease, over-

all survival has changed little during the last half century.

Most recently, the introduction of new cytotoxic agents, new

formulations of existing drugs, and variation of dose and

schedule have resulted in improvements in outcome with gen-

erally well tolerated toxicity profiles. The advantage of these

studies is not only seen in improved options for patients with

metastatic disease, but also in the ability to test more promis-

ing treatment approaches in the adjuvant, or early stage set-

ting.

Paclitaxel is a taxane derivative and among the most active

agents in the treatment of breast cancer. The mechanism of

action is related to disruption of microtubule disassembly

due to binding of paclitaxel to dimeric tubulin, resulting in

cessation of mitosis and eventual cell death. Response rates

in taxane naı̈ve metastatic breast cancer have ranged from

20–60% with activity noted in anthracycline pretreated dis-

ease. Randomized phase III trials of paclitaxel have high-

lighted the significance of dose and schedule on efficacy and

tolerability. Studies evaluating a dose relationship for pacli-

taxel documented improved response rates [77] at 175 mg/m2

compared to 135 mg/m2, but no differences and greater toxi-

city when higher doses were used [78]. Duration of exposure

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Table 8 BAY 43-9006, Carboplatin & paclitaxel preliminary ECOG data (Agarwala 2005) first consecutive patients enrolled as of 1/5/04, F/Uthrough 8/1/04

Gender Age

Male 28 (52%) Median 47 years

Female 26 (48%) Range 22 to 75 years

ECOG Performance status

0 35 (65%)

1 19 (35%)

AJCC Stage Prior systemic therapy

M1a 7 (13%) 0 23 (43%)

M1b 10 (19%) 1 19 (35%)

M1c 37 (68%) 2–4 12 (22%)

Best response: (investigator assessed) 95% CI

Partial response (PR) 20 (37%) [24–50%]

Stable disease (SD) 26 (48%)

Progression of disease (PD) 5 (9%)

Discontinuation other than PD 3 (6%)

of cycling cells to paclitaxel may be an important determi-

nant of anti-tumor efficacy [79, 80]. However, long dura-

tion infusions have been associated with increased hemato-

logic toxicity with an increase in efficacy at 24 but not 96

hours [81]. Weekly therapy appears to offer improved ef-

ficacy with reduced hematologic toxicity [82], as well as

a potential anti-angiogenic effect [83]. CALGB 9840 [84]

demonstrated an improvement in both response rate (40 vs.

28%, p = 0.017) and progression free survival (9 vs. 5 mo.,

p = 0.0008) from treatment with weekly paclitaxel com-

pared to every 3 week dosing. Interestingly, weekly dosing re-

sulted in reduced hematologic toxicity but increased sensory

neuropathy even with a mid-trial dose reduction from 100 to

80 mg/m2 per dose.

A major limitation of paclitaxel is its poor water solubil-

ity requiring Cremophor EL as a water soluble solvent. Cre-

mophor EL has been associated with significant side effects

including the risk of anaphylaxis [85]; premedication includ-

ing corticosteroids and antihistamines are typically used prior

to dosing to reduce this risk. Additional potential side effects

of Cremaphor EL include bone marrow suppression and pe-

ripheral neurotoxicity. In addition, because of poor solubil-

ity, paclitaxel must be dissolved in relatively large volumes

of fluid and is administered over a longer period of time (e.g.,

1 to 3 hours) than many other chemotherapy agents. Due to

the need for Cremaphor as a solvent, specialized intravenous

tubing is also required.

New formulations of existing agents have the advantage

of potentially modifying the toxicity profile as well as pos-

sibly improving tumor penetrance leading to enhanced ef-

ficacy [86]. Nab-paclitaxel is the first in its class of a bio-

logically interactive nanoparticle combining a protein with a

chemotherapeutic agent in the nanoparticle state. This novel

agent is an albumin bound, solvent free novel formulation of

the insoluble drug paclitaxel based on delivery in the form of

albumin-based nanoparticles of mean size about 120–130

nm and size range of approximately 50–150 nm (Fig. 1).

The nanoparticles are stable in liquid suspensions suitable

for injection. Nab-Paclitaxel is free of Cremaphor, therefore

eliminating the need for premedications and the risk of hy-

persensitivity from paclitaxel.

Binding hydrophobic drugs to albumin provides a novel

approach of potentially increasing the intra-tumoral concen-

tration of chemotherapeutic drugs utilizing albumin-specific

receptor transport mechanisms [87]. Generally, transporta-

tion of these agents across the endothelial cell membrane

depends on leaky endothelial cell junctions in tumor vascu-

lature, and is limited by increased intratumoral interstitial

pressure. Pre-clinical models have demonstrated that albu-

min binds to a specific receptor (gp60) on the endothelial

cell wall [88], resulting in activation of a protein termed

caveolin-1. Caveolin then initiates an opening in the endothe-

lial cell wall with formation of a little caves or caveolae, re-

sulting in transport of the albumin-bound chemotherapeutic

complex via these caveolae to the underlying tumor intersti-

tium [87]. Interestingly, increasing levels of caveolin-1 pro-

tein have been shown to correlate with progressive disease

in prostate cancer. The protein SPARC (Secreted Protein,

Acidic Rich in Cysteine) is secreted by a variety of tumors and

has been recently correlated with tumor aggressiveness and

poor prognostic outcomes in cancer [89–95]. SPARC [96,

97] may bind and entrap the albumin, allowing release of the

hydrophobic drug to the tumor cell membrane [96, 97]. If

ongoing and planned studies confirm the ability of albumin

bound drugs to leverage the gp-60/caveolin-1/caveolae/Sparc

pathway, thereby increasing intra-tumoral concentration of

drug and reducing toxicity to normal tissues, the implications

and impact of this formulation could be much broader. Pos-

sible tumor targeting of a chemotherapeutic agent could im-

prove efficacy and reduce toxicity of a number of therapeutics

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Fig. 3 Album in bound formulation of paclitaxel as a biologicallyinherative NaNo particle

including biologic agents, and offers interesting possibilities

for targeted imaging as well.

Preclinical studies comparing nab-paclitaxel to paclitaxel

demonstrated lower toxicities, with a maximum tolerated

dose (MTD) approximately 50% higher for nab-paclitaxel

compared to paclitaxel. At equal doses there was less myelo-

suppression and improved efficacy in a xenograft tumor

model of human mammary adenocarcinoma. At equitoxic

doses of paclitaxel, nab-paclitaxel was found to result in

greater tumor cell death than paclitaxel [98]. Preclinical mod-

els have demonstrated improved tolerability, increased an-

titumor activity and higher intratumor paclitaxel levels for

nab-paclitaxel compared to paclitaxel.

In a phase I study, the MTD of nab-paclitaxel was de-

termined to be 300 mg/m2 by 30 minute infusion every 3

weeks, without premedication or G-CSF support [99]. Two

multicenter phase II studies evaluated two dose levels of nab-

paclitaxel (300 mg/m2, n = 63, and 175 mg/m2, n = 43) in

patients with metastatic breast cancer [100, 101]. The over-

all response rates in these two phase II trials was 40% (95%

CI 25–54%) for the 175 mg/m2 dose, and 48% (95% CI

35–60%) for the 300 mg/m2 dose. Of 39 patients receiving

300 mg/m2 as first-line therapy for metastatic breast cancer,

64% (95% CI 49–79%) responded. This was contrasted with

a 45% response rate in similar patients at the lower dose

level (175 mg/m2). Grade 4 neutropenia was noted in 24%

of patients at the 300 mg/m2 dose level, occurring primar-

ily during the first cycle with rapid resolution. A Phase III

trial in patients with metastatic breast cancer compared nab-

paclitaxel 260 mg/m2 to paclitaxel 175 mg/m2 given every 3

weeks [102]. Significantly higher efficacy for nab-paclitaxel

versus paclitaxel was demonstrated as measured by over-

all response rates (33% vs. 19%, p < 0.001) and time to

tumor progression (5.0 vs. 3.7 months, p = 0.03). The in-

cidence of grade 4 neutropenia was significantly lower in

the nab-paclitaxel group (9% vs. 22%; P < 0.001) despite

a 49% higher paclitaxel dose. Grade 3 sensory neuropa-

thy was more common in the nab-paclitaxel group than in

the paclitaxel group (10% vs. 2%; P < 0.001) but was eas-

ily managed and improved rapidly (median, 22 days). No

hypersensitivity reactions occurred with nab-paclitaxel de-

spite the absence of premedication and shorter administration

time.

A Phase I study of nab-paclitaxel administered weekly

for 3 weeks followed by a 1 week rest in patients with

advanced solid tumors has recently been completed [103].

The MTDs for heavily and lightly pre-treated patients were

100 and 150 mg/m2 respectively. Dose limiting toxicities

included myelosuppression and peripheral neuropathy. In

a Phase II trial in heavily pretreated patients with taxane-

refractory metastatic breast cancer, objective antitumor re-

sponses occurred in 12 to 15% of women treated with weekly

nab-paclitaxel at 100 or 125 mg/m2 on a 3 week on, 1 week

off schedule [104, 105]. Nab-paclitaxel was extremely well

tolerated when administered weekly over 30 minutes with-

out steroids or G-CSF prophylaxis. Only 1% of patients in

the 100 mg/m2 group and 3% in the 125 mg/m2 group ex-

perienced grade 4 neutropenia. There were no incidents of

grade 4 nonhematologic toxicities, and no severe hypersen-

sitivity reactions. Grade 3 sensory neuropathy was experi-

enced by 4% of patients in the 100 mg/m2 group. At the

125 mg/m2 dose level, the incidence of Grade 3 sensory

neuropathy (17%) was less than that reported in patients

with metastatic breast cancer receiving weekly paclitaxel 100

mg/m2 as first-line therapy. As was seen with every 3 week

dosing of nab-paclitaxel, the majority of patients with grade

3 sensory neuropathy recovered to grade 2 or less within 21

days and were retreated at a lower dose without significant

toxicity.

The area of chemotherapeutic tumor targeting has gener-

ally focused on finding unique antigens or other targets on

the tumor cell surface; a research area that has been chal-

lenging and less than successful in the treatment of solid

tumors. Targeting a standard transport mechanism that is nat-

urally enhanced in tumors is a unique approach that has al-

ready resulted in the FDA approval of nab-paclitaxel (Abrax-

ane) for the treatment of metastatic breast cancer, and is an

exciting new direction in both reducing toxicity of potent

anti-cancer agents, and increasing efficacy by possible tu-

mor targeting. Studies evaluating nab-paclitaxel in other tu-

mor types are ongoing, and new nab-formulations are being

developed.

– Rugo H, Tripathy D: New developments in cancer ther-

apeutics targeting HER2/neu and other growth factor re-

ceptors. Biotechnology International 2001:203–212.

References

1. Mendelsohn J, Baselga J: The EGF receptor family as targets forcancer therapy. Oncogene 19(56): 6550–6565, 2000

2. Ang KK, Berkey BA, Tu X, et al.: Impact of epidermal growthfactor receptor expression on survival and pattern of relapse in pa-

Springer


tients with advanced head and neck carcinoma. Cancer Res 62(24):7350–7356, 2002

3. Baselga J, Arteaga CL: Critical update and emerging trends inepidermal growth factor receptor targeting in cancer. J Clin Oncol23(11): 2445–2459, 2005

4. Fukuoka M, Yano S, Giaccone G, Tamura T, Nakagawa K,Douillard JY, Nishiwaki Y, Vansteenkiste J, Kudoh S, Rischin D,Eek R, Horai T, Noda K, Takata I, Smit E, Averbuch S, MacleodA, Feyereislova A, Dong RP, Baselga J: Multi-institutional ran-domized phase II trial of gefitinib for previously treated patientswith advanced non-small-cell lung cancer (The IDEAL 1 Trial)[corrected]. J Clin Oncol 21(12): 2237–2246, 2003

5. Kris MG, Natale RB, Herbst RS, Lynch TJ Jr, Prager D, BelaniCP, Schiller JH, Kelly K, Spiridonidis H, Sandler A, AlbainKS, Cella D, Wolf MK, Averbuch SD, Ochs JJ, Kay AC: Ef-ficacy of gefitinib, an inhibitor of the epidermal growth factorreceptor tyrosine kinase, in symptomatic patients with non-smallcell lung cancer: A randomized trial. Jama 290(16): 2149–2158,2003

6. Perez-Soler R, Chachoua A, Hammond LA, Rowinsky EK, Hu-berman M, Karp D, Rigas J, Clark GM, Santabarbara P, BonomiP.: Determinants of tumor response and survival with erlotinib inpatients with non–small-cell lung cancer. J Clin Oncol 22(16):3238–3247, 2004

7. Shepherd FA, Pereira J, Ciuleanu TE, et al.: A randomizedplacebo-controlled trial of erlotinib in patients with advanced non-small cell lung cancer (NSCLC) following failure of 1st line or 2nd

line chemotherapy. A National Cancer Institute of Canada Clini-cal Trials Group (NCIC CTG) trial. Journal of Clinical Oncology22(14S): A7022, 2004

8. Thatcher N, Chang A, Parikh P, Pemberton K, Archer V: Re-sults of a phase III placebo-controlled study (ISEL) of gefitinib(IRESSA) plus best supportive care (BSC) in patients with ad-vanced non-small-cell lung cancer (NSCLC) who had received 1or 2 prior chemotherapy regimens. Proc Amer Assoc Cancer Res46: Abstract LB-6, 2005

9. Giaccone G, Herbst RS, Manegold C, Scagliotti G, Rosell R,Miller V, Natale RB, Schiller JH, Von Pawel J, Pluzanska A,Gatzemeier U, Grous J, Ochs JS, Averbuch SD, Wolf MK, RennieP, Fandi A, Johnson DH.: Gefitinib in combination with gemc-itabine and cisplatin in advanced non-small-cell lung cancer: Aphase III trial–INTACT 1. J Clin Oncol 22(5): 777–784, 2004

10. Herbst RS, Giaccone G, Schiller JH, Natale RB, Miller V, Mane-gold C, Scagliotti G, Rosell R, Oliff I, Reeves JA, Wolf MK, KrebsAD, Averbuch SD, Ochs JS, Grous J, Fandi A, Johnson DH: Gefi-tinib in combination with paclitaxel and carboplatin in advancednon-small-cell lung cancer: A phase III trial–INTACT 2. J ClinOncol 22(5): 785–794, 2004

11. Lilenbaum R, Bonomi P, Ansari R, et al.: A phase II trial of cetux-imab as therapy for recurrent non-small cell lung cancer (NSCLC):Final results. Proc Am Soc Clin Oncol A7036, 2005

12. Rosell R, Daniel C, Ramlau R, et al.: Randomized phase II studyof cetuximab in combination with cisplatin (C) and vinorelbine(V) vs. CV alone in the first-line treatment of patients (pts) withepidermal growth factor receptor (EGFR)-expressing advancednon-small-cell lung cancer (NSCLC). Proc Am Soc Clin OncolA7012, 2004

13. Bonner JA, Giralt J, Harari PM, et al.: Cetuximab prolongs survivalin patients with locoregionally advanced squamous cell carcinomaof head and neck: A phase III study of high dose radiation therapywith or without cetuximab. Proc Am Soc Clin Oncol 22(14S):A5507, 2004

14. Burtness BA, Li Y, Flood W, Mattar BI, Forastiere AA: PhaseIII trial comparing cisplatin (C) + placebo (P) to C + anti-epidermal growth factor antibody (EGF-R) C225 in patients (pts)

with metastatic/recurrent head & neck cancer (HNC). Proc AmSoc Clin Oncol 21: A901, 2002

15. Trigo J, Hitt R, Koralewski P, et al.: Cetuximab monotherapy is ac-tive in patients (pts) with platinum-refractory recurrent/metastaticsquamous cell carcinoma of the head and neck (SCCHN): Resultsof a phase II study. Proc Am Soc Clin Oncol 22(14S): A5502, 2004

16. Cohen EE, Rosen F, Stadler WM, Recant W, Stenson K, HuoD, Vokes EE: Phase II trial of ZD1839 in recurrent or metastaticsquamous cell carcinoma of the head and neck. J Clin Oncol21(10): 1980–1987, 2003

17. Soulieres D, Senzer NN, Vokes EE, Hidalgo M, Agarwala SS,Siu LL: Multicenter phase II study of erlotinib, an oral epidermalgrowth factor receptor tyrosine kinase inhibitor, in patients withrecurrent or metastatic squamous cell cancer of the head andneck. J Clin Oncol 22(1): 77–85, 2004

18. Kane MA, Cohen E, List M, et al.: Phase II study of 250 mggefitinib in advanced squamous cell carcinoma of the head andneck (SCCHN). Proc Am Soc Clin Oncol A5586, 2004

19. Moore MJ, Goldstein D, Hamm J, et al.: Erlotinib plus gemc-itabine compared to gemcitabine alone in patients with advancedpancreatic cancer. A phase III trial of the National Cancer Instituteof Canada Clinical Trials Group [NCIC-CTG]. Proc Am Soc ClinOncol A1, 2005

20. Saltz LB, Meropol NJ, Loehrer PJ, Sr., Needle MN, Kopit J,Mayer RJ: Phase II trial of cetuximab in patients with refractorycolorectal cancer that expresses the epidermal growth factorreceptor. J Clin Oncol 22(7): 1201–1208, 2004

21. Cunningham D, Humblet Y, Siena S, Khayat D, Bleiberg H,Santoro A, Bets D, Mueser M, Harstrick A, Verslype C, ChauI, Van Cutsem E: Cetuximab monotherapy and cetuximab plusirinotecan in irinotecan-refractory metastatic colorectal cancer. NEngl J Med 351(4): 337–345, 2004

22. Chung KY, Shia J, Kemeny NE, Shah M, Schwartz GK, Tse A,Hamilton A, Pan D, Schrag D, Schwartz L, Klimstra DS, FridmanD, Kelsen DP, Saltz LB: Cetuximab shows activity in colorectalcancer patients with tumors that do not express the epidermalgrowth factor receptor by immunohistochemistry. J Clin Oncol23(9): 1803–1810, 2005

23. Keilholz U, Arnold D, Niederle N, et al.: Erlotinib as 2nd and 3rdline monotherapy in patients with metastatic colorectal cancer.Results of a multicenter two-cohort phase II trial. Proc Am SocClin Oncol A3575, 2005

24. Janne PA, Engelman JA, Johnson BE: Epidermal growth factorreceptor mutations in non-small-cell lung cancer: Implications fortreatment and tumor biology. J Clin Oncol 23(14): 3227–3234,2005

25. Cappuzzo F, Hirsch FR, Rossi E, Bartolini S, Ceresoli GL, BemisL, Haney J, Witta S, Danenberg K, Domenichini I, Ludovini V,Magrini E, Gregorc V, Doglioni C, Sidoni A, Tonato M, FranklinWA, Crino L, Bunn PA Jr, Varella-Garcia M: Epidermal growthfactor receptor gene and protein and gefitinib sensitivity in non-small-cell lung cancer. J Natl Cancer Inst 97(9): 643–655, 2005

26. Moroni M, Veronese S, Benvenuti S, Marrapese G, Sartore-Bianchi A, Di Nicolantonio F, Gambacorta M, Siena S, Bardelli A:Gene copy number for epidermal growth factor receptor (EGFR)and clinical response to antiEGFR treatment in colorectal cancer:A cohort study. Lancet Oncol 6(5): 279–286, 2005

27. Pao W, Wang TY, Riely GJ, Miller VA, Pan Q, Ladanyi M, Za-kowski MF, Heelan RT, Kris MG, Varmus HE: KRAS Mutationsand primary resistance of lung adenocarcinomas to gefitinib orerlotinib. PLoS Med 2(1): e17, 2005

28. Cappuzzo F, Magrini E, Ceresoli GL, Bartolini S, Rossi E,Ludovini V, Gregorc V, Ligorio C, Cancellieri A, Damiani S,Spreafico A, Paties CT, Lombardo L, Calandri C, Bellezza G,Tonato M, Crino L: Akt phosphorylation and gefitinib efficacy in

Springer


patients with advanced non-small-cell lung cancer. J Natl CancerInst 96(15): 1133–1141, 2004

29. Saltz L, Kies M, Abbruzzese JL, Azarnia N, Needle M: Thepresence and intensity of the cetuximab-induced acne-likerash predicts increased survival in studies across multiplemalignancies. Proc Am Soc Clin Oncol 22: A817, 2003

30. Amador ML, Oppenheimer D, Perea S, Maitra A, Cusati G,Iacobuzio-Donahue C, Baker SD, Ashfaq R, Takimoto C,Forastiere A, Hidalgo M: An epidermal growth factor receptorintron 1 polymorphism mediates response to epidermal growthfactor receptor inhibitors. Cancer Res 64(24): 9139–9143,2004

31. Karkkainen MJ, Petrova TV: Vascular endothelial growth factorreceptors in the regulation of angiogenesis and lymphangiogen-esis. Oncogene 19: 5598–5605, 2000

32. Dvork HF: Rous-Whipple Award Lecture: How tumors makebad blood vessels and stroma. Am J Pathol 162: 1747–1757,2003

33. Carmeliet P, Ferreira V, Breier G, Pollefeyt S, Kieckens L,Gertsenstein M, Fahrig M, Vandenhoeck A, Harpal K, EberhardtC, Declercq C, Pawling J, Moons L, Collen D, Risau W, NagyA: Abnormal blood vessel development and lethality in embryoslacking a single VEGF allele. Nature 380: 535–439, 1996

34. Hicklin DJ, Ellis LM: Role of the vascular endothelial growthfactor pathway in tumor growth and angiogenesis. J Clin OncolIn press

35. Tsuzuk Y, Fukumura D, Oosthuyse B, Koike C, Carmeliet P, JainRK: VEGF modulation by targeting HIF-1a→HRE→VEGFcascade differentially regulates vascular response and growth ratein tumors. Cancer Res 60: 6248–6252, 2000

36. Ferrara N, Gerber HP, Lecouter J: The biology of VEGF and itsreceptors. Nat Med 9: 669–676, 2003

37. Willett CG, Boucher Y, di Tomaso E, Duda DG, Munn LL, TongRT, Chung DC, Sahani DV, Kalva SP, Kozin SV, Mino M, CohenKS, Scadden DT, Hartford AC, Fischman AJ, Clark JW, RyanDP, Zhu AX, Blaszkowsky LS, Chen HX, Shellito PC, LauwersGY, Jain RK: Direct evidence that the VEGF-specific antibodybevacizumab has anti vascular effects in human rectal cancer. NatMed 10: 145–147, 2004

38. Hillan KJ, Koeppen HKW, Tobin P, et al.: The role of VEGFexpression in response to bevacizumab plus capecitabine inmetastatic breast cancer (MBC). Proc Am Soc Clin Oncol 22:191. Abstract 766, 2003

39. Hurwitz H, Fehrenbacher L, Novotny W, Cartwright T,Hainsworth J, Heim W, Berlin J, Baron A, Griffing S, Holm-gren E, Ferrara N, Fyfe G, Rogers B, Ross R, Kabbinavar F:Bevacizumab plus irinotecan, fluorouracil, and leucovorin formetastatic colorectal cancer. N Engl J Med 350: 2335–2342, 2004

40. Kabbinavar FF, Hambleton J, Mass RD, Hurwitz HI, BergslandE, Sarkar S: Combined analysis of efficacy: The addition ofbevacizumab to fluorouracil/leucovorin improves survival forpatients with metastatic colorectal cancer. J Clin Oncol. 23:3706–3712, 2005

41. Giantonio BJ, Catalano PJ, Meropol NH, et al.: High dosebevacizumab improves survival when combined with FOLFOXin previously treated advanced colorectal cancer: Results fromthe Eastern Cooperative Oncology Group (ECOG) study E3200.Proc Am Soc Clin Onc. Presentation and Abstract 169A,2005

42. Saltz LB, Lenz H, Hochster H, et al.: Randomized phase IItrial of cetuximab/bevacizumab/irinotecan (CBI) versus ce-tuximab/bevacizumab (CB) in irinotecan-refractory colorectalcancer [clarification to data given by LB Saltz, personal commu-nication, July 27, 2005]. Proc Am Soc Clin Onc Abstract 3508,2005

43. Kabbinavar F: ASCO, 2005

44. Johnson DH, Fehrenbacher L, Novotny WF, Herbst RS, Nemu-naitis JJ, Jablons DM, Langer CJ, DeVore RF 3rd, Gaudreault J,Damico LA, Holmgren E, Kabbinavar F: Randomized phase IItrial comparing bevacizumab plus carboplatin and paclitaxel withcarboplatin and paclitaxel alone in previous untreated locallyadvanced or metastatic non-small-cell lung cancer. J Clin Oncol22: 2184–2191, 2004

45. Sandler AB, Gray R, Brahmer J, et al.: Randomized phase II/IIItrial of paclitaxel plus carboplatin with or without bevacizumab inpatients with advanced non-squamous non-small cell lung cancer(NSCLC): An Eastern Cooperative Oncology Group (ECOG)trial-E 4599. Proc Am Soc Clin Onc Presentation and AbstractLBA4, 2005

46. Sandler AB: Personal communication. June 20, 200547. Holash J, Davis S, Papadopoulos N, Croll SD, Ho L, Russell

M, Boland P, Leidich R, Hylton D, Burova E, Ioffe E, HuangT, Radziejewski C, Bailey K, Fandl JP, Daly T, Wiegand SJ,Yancopoulos GD, Rudge JS: VEGF-Trap: A VEGF blockerwith potent antitumor effects. Proc Natl Acad Sci USA 99:11393–11398, 2002

48. Dupont J, Schwartz J, Koutcher J, et al.: Phase I and pharma-cokinetic study of VEGF trap administered subcutaneously topatients with advanced solid malignancies. Proc Am Soc ClinOnc Abstract 3009, 2004

49. Dupont J, Rothenberg ML, Spriggs DR, et al.: Safety andpharmacokinetics if intravenous VEGF Trap in a phase I clinicaltrial of patients with advanced solid tumors. Proc Am Soc ClinOnc Abstract 3029, 2005

50. Huang J, Frischer JS, Serur A, Kadenhe A, Yokoi A, McCruddenKW, New T, O’Toole K, Zabski S, Rudge JS, Holash J, Yancopou-los GD, Yamashiro DJ, Kandel JJ: Regression of establishedtumors and metastases by potent vascular endothelial growthfactor blockade. Proc Natl Acad Sci USA 100: 7785–7790,2003

51. Wood JM, Bold G, Buchdunger E, Cozens R, Ferrari S, Frei J,Hofmann F, Mestan J, Mett H, O’Reilly T, Persohn E, Rosel J,Schnell C, Stover D, Theuer A, Towbin H, Wenger F, Woods-Cook K, Menrad A, Siemeister G, Schirner M, Thierauch KH,Schneider MR, Drevs J, Martiny-Baron G, Totzke F: PTK/ZK222584, a novel and potent inhibitor of vascular endothelialgrowth factor receptor tyrosine kinases, impairs vascular en-dothelial growth factor-induced responses and tumor growth afteroral administration. Cancer Res 60: 2178–2189, 2000

52. Heinrich MC, Blanke CD, Druker BJ, Corless CL: Inhibitionof KIT tyrosine kinase activity: A novel molecular approach tothe treatment of KIT tyrosine kinase activity: A novel molecularapproach to the treatment of KIT-positive malignancies. J ClinOncol 20: 1692–1703, 2002

53. Rini B, Rixe O, Bukowski R, et al.: AG-013736, a multi-targettyrosine kinase receptor inhibitor, demonstrates antitumor activityin a phase 2 study of cytokine-refractory, metastatic renal cellcancer (RCC). Proc Am Soc Clin Onc Presentation and Abstract4509, 2005

54. Hecht JR, Trarbach T, Jaeger E, et al.: A randomized, double-blind, placebo-controlled, phase III study in patients withmetastatic adenocarcinoma of the colon or rectum receiving first-line chemotherapy with oxaliplatin/5-fluorouracil-leukovorinand PTK787/ZK 222584 or placebo (CONFIRM-1). Proc AmSoc Clin Onc Abstract LBA3. Presentation and Abstract LBA3,2005

55. Ryan AJ, Wedge SR: ZD6474-a novel inhibitor of VEGFR andEGFR tyrosine kinase activity. Br J Cancer 92 Suppl 1: S6–13,2005

56. Wilhelm SM, Carter C, Tang L, Wilkie D, McNabola A, RongH, Chen C, Zhang X, Vincent P, McHugh M, Cao Y, Shujath J,Gawlak S, Eveleigh D, Rowley B, Liu L, Adnane L, Lynch M,

Springer


Auclair D, Taylor I, Gedrich R, Voznesensky A, Riedl B, PostLE, Bollag G, Trail PA: BAY 43-9006 exhibits broad spectrumoral antitumor activity and targets the RAF/MEK/ERK pathwayand receptor tyrosine kinases involved in tumor progression andangiogenesis. Cancer Res 64: 7099–7109, 2004

57. Mendel DB, Laird AD, Xin X, Louie SG, Christensen JG, Li G,Schreck RE, Abrams TJ, Ngai TJ, Lee LB, Murray LJ, CarverJ, Chan E, Moss KG, Haznedar JO, Sukbuntherng J, Blake RA,Sun L, Tang C, Miller T, Shirazian S, McMahon G, CherringtonJM: In vivo antitumor activity of SU11248, a novel tyrosinekinase inhibitor targeting vascular endothelial growth factorand platelet-derived growth factor receptors: Determination ofa pharmacokinetic/pharmacodynamic relationship. Clin CancerRes 9: 327–337, 2003

58. Motzer RJ, Rini BI, Michaelson BG, et al.: Phase 2 trials ofSU11248 show antitumor activity in second-line therapy forpatients with metastatic renal cell carcinoma (RCC). Proc AmSoc Clin Onc Presentation and Abstract 4508, 2005

59. Davies Hl, Bignell GR, Cox C, Stephens P, Edkins S, CleggS, Teague J, Woffendin H, Garnett MJ, Bottomley W, DavisN, Dicks E, Ewing R, Floyd Y, Gray K, Hall S, Hawes R,Hughes J, Kosmidou V, Menzies A, Mould C, Parker A, StevensC, Watt S, Hooper S, Wilson R, Jayatilake H, Gusterson BA,Cooper C, Shipley J, Hargrave D, Pritchard-Jones K, MaitlandN, Chenevix-Trench G, Riggins GJ, Bigner DD, Palmieri G,Cossu A, Flanagan A, Nicholson A, Ho JW, Leung SY, YuenST, Weber BL, Seigler HF, Darrow TL, Paterson H, Marais R,Marshall CJ, Wooster R, Stratton MR, Futreal PA: Mutationsof the BRAF gene in human cancer. Nature 417: 949–954,2002

60. Daniotti M, Oggionni M, Ranzani T, Vallacchi V, Campi V, DiStasi D, Torre GD, Perrone F, Luoni C, Suardi S, Frattini M,Pilotti S, Anichini A, Tragni G, Parmiani G, Pierotti MA, RodolfoM: BRAF alterations are associated with complex mutationalprofiles in malignant melanoma. Oncogene. 23: 5968–5977,2004

61. Pollock PM, Harper UL, Hansen KS, Yudt LM, Stark M, RobbinsCM, Moses TY, Hostetter G, Wagner U, Kakareka J, Salem G,Pohida T, Heenan P, Duray P, Kallioniemi O, Hayward NK, TrentJM, Meltzer PS: High frequency of BRAF mutations in nevi. NatGenet 33: 19–20, 2003

62. Demunter A, Stash M, Degreef H, De Wolf-Peeters C, van denOord JJ: Analysis of N- and K-ras mutations in the distinctivetumor progression phases of melanoma. J Invest Dermatol 117:1483–1489, 2001

63. Gorden A, Osman I, Gai W, He D, Huang W, Davidson A,Houghton AN, Busam K, Polsky D: Analysis of BRAF andN-RAS mutations in metastatic melanoma tissues. Cancer Res63: 3955–3957, 2003

64. Rodolfo M, Daniotti M, Vallacchi V: Genetic progression ofmetastatic melanoma. Cancer Lett 214: 133–147, 2004

65. Garnett & Morais, Cancer Cell 200466. Kumar R, Angelini S, Snellman E, Hemminki K: BRAF muta-

tions are common somatic events in melanocytic nevi. J InvestDermatol 122: 342–348, 2004

67. Yazdi AS, Palmedo G, Flaig MJ, Puchta U, Reckwerth A, RuttenA, Mentzel T, Hugel H, Hantschke M, Schmid-Wendtner MH,Kutzner H, Sander CA: Mutations of the BRAF gene in benignand malignant melanocytic lesions. J Invest Dermatol 121:1160–1162, 2003

68. Cohen Y, Goldenberg-Cohen N, Parrella P, Chowers I, MerbsSL, Pe’er J, Sidransky D: Lack of BRAF mutation in primaryuveal melanoma. Invest Ophthalmol Vis Sci 44: 2876–2878,2003

69. Edwards, RH, Ward MR, Wu H, Medina CA, Brose MS, VolpeP, Nussen-Lee S, Haupt HM, Martin AM, Herlyn M, LessinSR, Weber BL: Absence of BRAF mutations in UV-protectedmucosal melanomas. J Med Genet 41: 270–272, 2004

70. Lyons JF, Wilhelm S, Hibner B, Bollag G: Discovery of a novelRaf kinase inhibitor. Endocr Relat Cancer 8: 219–225, 2001

71. Wilhelm SM, Carter C, Tang L, Wilkie D, McNabola A, RongH, Chen C, Zhang X, Vincent P, McHugh M, Cao Y, ShujathJ, Gawlak S, Eveleigh D, Rowley B, Liu L, Adnane L, LynchM, Auclair D, Taylor I, Gedrich R, Voznesensky A, Riedl B,Post LE, Bollag G, Trail PA: BAY 43-9006 exhibits broadspectrum oral antitumor activity and targets the RAF/MEK/ERKpathway and receptor tyrosine kinases involved in tumorprogression and angio-genesis. Cancer Res 64: 7099–7109,2004

72. Strumberg D, et al.: Results of phase I pharmacokinetic andpharmacodynamic studies of the Raf kinase inhibitor BAY43-9006 in patients with solid tumors. Int J Clin Pharmacol Ther41: 620–621, 2002

73. Ratain MJ, et al.: Preliminary antitumor activity of BAY 43-9006in metastatic renal cell carcinoma and other advanced refractorysolid tumors in a phase II randomized discontinuation trial (RDT)[abstract]. ASCO Annual Meeting Proceedings. J Clin Oncol22(Suppl.): 4501, June 5–8, 2004

74. Ahmad T, et al.: BAY 43-9006 in patients with advancedmelanoma: The Royal Marsden Experience [abstract]. 2004ASCO Annual Meeting Proceedings. June 5–8, J Clin Oncol22(Suppl.): 7506, 2004

75. Flaherty KT, et al.: Phase I/II trial of Bay 43-9006, carboplatin (C)and paclitaxel (P) demonstrates preliminary antitumor activityin the expansion cohort of patients with metastatic melanoma[abstract]. 2004 ASCO Annual Meeting Proceedings June 5–8, JClin Oncol 22(Suppl.): 7507, 2004

76. Greenberg PA, Hortobagyi GN, Smith TL, Ziegler LD, FryeDK, Buzdar AU: Long-term follow-up of patients with completeremission following combination chemotherapy for metastaticbreast cancer. J Clin Oncol 14: 2197–205, 1996

77. Nabholtz JM, Gelmon K, Bontenbal M, Spielmann M, CatimelG, Conte P, Klaassen U, Namer M, Bonneterre J, Fumoleau P,Winograd B: Multicenter, randomized comparative study of twodoses of paclitaxel in patients with metastatic breast cancer. JClin Oncol 14: 1858–1867, 1996

78. Winer EP, Berry DA, Woolf S, Duggan D, Kornblith A, HarrisLN, Michaelson RA, Kirshner JA, Fleming GF, Perry MC,Graham ML, Sharp SA, Keresztes R, Henderson IC, Hudis C,Muss H, Norton L: Failure of higher-dose paclitaxel to improveoutcome in patients with metastatic breast cancer: Cancer andleukemia group B trial 9342. J Clin Oncol 22: 2061–2068,2004

79. Seidman AD, Hochhauser D, Gollub M, Edelman B, Yao TJ,Hudis CA, Francis P, Fennelly D, Gilewski TA, Moynahan ME,Currie V, Baselga J, Tong W, O’Donaghue M, Salvaggio R,Auguste L, Spriggs D, Norton L: Ninety-six-hour paclitaxelinfusion after progression during short taxane exposure: A phaseII pharmacokinetic and pharmacodynamic study in metastaticbreast cancer. J Clin Oncol 14: 1877–1884, 1996

80. Lopes NM, Adams EG, Pitts TW, Bhuyan BK: Cell kill kineticsand cell cycle effects of taxol on human and hamster ovarian celllines. Cancer Chemother Pharmacol 32: 235–242, 1993

81. Di Leo A, Piccart MJ: Paclitaxel activity, dose, and schedule:Data from phase III trials in metastatic breast cancer. SeminOncol 26: 27–32, 1999

82. Seidman AD, Hudis CA, Albanell J, Tong W, Tepler I, CurrieV, Moynahan ME, Theodoulou M, Gollub M, Baselga J, Norton

Springer


L: Dose-dense therapy with weekly 1-hour paclitaxel infusionsin the treatment of metastatic breast cancer. J Clin Oncol 16:3353–3361, 1998

83. Kerbel RS, Viloria-Petit A, Klement G, Rak J: ‘Accidental’anti-angiogenic drugs. anti-oncogene directed signal transductioninhibitors and conventional chemotherapeutic agents as examples.Eur J Cancer 36: 1248–1257, 2000

84. Seidman AD, Berry D, Cirrincione C, et al.: CALGB 9840: PhaseIII study of weekly (W) paclitaxel (P) via 1-hour(h) infusionversus standard (S) 3h infusion every third week in the treatmentof metastatic breast cancer (MBC), with trastuzumab (T) forHER2 positive MBC and randomized for T in HER2 normalMBC. J Clin Oncol, 2004 ASCO Proc 22(14S): 512, 2004

85. Shepherd GM: Hypersensitivity reactions to chemotherapeuticdrugs. Clin Rev Allergy Immunol 24: 253–262, 2003

86. Abi 007. Drugs R D 5:155–159, 200487. Desai N, Trieu V, Yao R, et al.: Increased endothelial transcytosis

of nanoparticle albumin-bound paclitaxel (ABI-007) by gp60-receptors: A pathway inhibited by taxol. Breast Cancer Res Treat88(S1): 1071, 2004

88. Carver LA, Schnitzer JE: Caveolae: Mining little caves for newcancer targets. Nat Rev Cancer 3: 571–581, 2003

89. Koukourakis MI, Giatromanolaki A, Brekken RA, SivridisE, Gatter KC, Harris AL, Sage EH: Enhanced expression ofSPARC/osteonectin in the tumor-associated stroma of non-smallcell lung cancer is correlated with markers of hypoxia/acidity andwith poor prognosis of patients. Cancer Res 63: 5376–5380, 2003

90. Rumpler G, Becker B, Hafner C, McClelland M, Stolz W,Landthaler M, Schmitt R, Bosserhoff A, Vogt T: Identification ofdifferentially expressed genes in models of melanoma progressionby cDNA array analysis: SPARC, MIF and a novel cathepsinprotease characterize aggressive phenotypes. Exp Dermatol 12:761–771, 2003

91. Sangaletti S, Stoppacciaro A, Guiducci C, Torrisi MR, ColomboMP: Leukocyte, rather than tumor-produced SPARC, determinesstroma and collagen type IV deposition in mammary carcinoma.J Exp Med 198: 1475–1485, 2003

92. Sato N, Fukushima N, Maehara N, Matsubayashi H, Koopmann J,Su GH, Hruban RH, Goggins M: SPARC/osteonectin is a frequenttarget for aberrant methylation in pancreatic adenocarcinomaand a mediator of tumor-stromal interactions. Oncogene 22:5021–5030, 2003

93. Vadlamuri SV, Media J, Sankey SS, Nakeff A, Divine G, RempelSA: SPARC affects glioma cell growth differently when grown onbrain ECM proteins in vitro under standard versus reduced-serumstress conditions. Neuro-oncol 5: 244–254, 2003

94. Yamashita K, Upadhay S, Mimori K, Inoue H, Mori M: Clinicalsignificance of secreted protein acidic and rich in cystein in

esophageal carcinoma and its relation to carcinoma progression.Cancer 97: 2412–2419, 2003

95. Schneider S, Yochim J, Brabender J, Uchida K, Danenberg KD,Metzger R, Schneider PM, Salonga D, Holscher AH, DanenbergPV: Osteopontin but not osteonectin messenger RNA expressionis a prognostic marker in curatively resected non-small cell lungcancer. Clin Cancer Res 10: 1588–1596, 2004

96. Desai N, Trieu V, Yao R, et al.: SPARC expression in breast tumorsmay correlate to increased tumor distribution of nanoparticlealbumin-bound paclitaxel (ABI-007) vs. taxol. Breast Cancer ResTreat 88(S1): 206, 2004

97. Trieu V, Frankel T, Labao E, et al.: SPARC expression inbreast tumors may correlate to increased tumor distribution ofnanoparticle albumin-bound paclitaxel (ABI-007) vs. taxol. ProcAmer Assoc Cancer Res 46: 5584, 2005

98. Desai N, Yao Z, Soon-Shiong P, et al.: Evidence of enhanced invivo efficacy at Maximum Tolerated Dose (MTD) of NanoparticlePaclitaxel (ABI-007) and Taxol in 5 Human Tumor Xenograftsof Varying Sensitivity to Paclitaxel. Proc Am Soc Clin Oncol 21:462, 2002

99. Ibrahim NK, Desai N, Legha S, Soon-Shiong P, Theriault RL,Rivera E, Esmaeli B, Ring SE, Bedikian A, Hortobagyi GN,Ellerhorst JA: Phase I and pharmacokinetic study of ABI-007, aCremophor-free, protein-stabilized, nanoparticle formulation ofpaclitaxel. Clin Cancer Res 8: 1038–1044, 2002

100. Abi 007. Drugs R D 4: 303–305, 2003101. Ibrahim NK, Samuels B, Page R, Doval D, Patel KM, Rao SC,

Nair MK, Bhar P, Desai N, Hortobagyi GN: Multicenter phaseII trial of ABI-007, an albumin-bound paclitaxel, in womenwith metastatic breast cancer. J Clin Oncol 23: 6019–6026,2005

102. Gradishar WJ, Tjulandin S, Davidson N, Shaw H, Desai N, BharP, Hawkins M, O’Shaughnessy J: Phase III trial of nanoparticlealbumin-bound paclitaxel compared with polyethylated castoroil-based paclitaxel in women with breast cancer. J Clin Oncol23: 7794–7803, 2005

103. Nyman DW, Campbell KJ, Hersh E, Long K, Richardson K,Trieu V, Desai N, Hawkins MJ, Von Hoff DD: Phase I andpharmacokinetics trial of ABI-007, a novel nanoparticle formu-lation of paclitaxel in patients with advanced nonhematologicmalignancies. J Clin Oncol 23: 7785–7793, 2005

104. O’Shaughnessy JA, Blum JL, Sandbach JF, et al.: Weeklynanoparticle albumin paclitaxel (Abraxane) results in long-termdisease control in patients with taxane-refractory metastaticbreast cancer. Breast Cancer Res Treat 88 (S1): 1070, 2004

105. Blum JL, Savin MA, Edelman G, et al.: Long term disease controlin taxane-refractory metastatic breast cancer treated with nabpaclitaxel. Proc Am Soc Clin Oncol 22(14S): 543, 2004

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Targeting growth factors and angiogenesis; using small molecules in malignancy

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