6th Latin American Medical Education Workshop

MOLECULAR TARGETED THERAPY

OF CANCER

Brain Tumors

Mauricio Lema Medina

 Glioblastoma

 Most frequent malignant glioma: 2/3

 Worst median survival: 12 mo
 Two groups
 Primary GBM
 De novo
 >50 years
 Secondary GBMs
 Progression of lower grade gliomas
 <50 years
 Glioblastoma - Pathology

 Dense cell proliferation

 Extensive nuclear
polymorphism,
 High mitotic activity
 Necrosis
 Serpentine
 Pseudopalisade formation.
 Vascular endothelial cell
proliferation
 Double layer of endothelial
cell
 Cell-of-origin: Gliomas
Olig2 expression (100%)
p53 mutated (>65%)
PDGFA/PDGFR (60%)
Low-Grade Astrocytoma
LOH19q (50%)
RB mutated (25%)
CDK4 amplified (15%)
MDM2 overexp. (10%)
p16 loss (4%)
LOH 11p (30%)
Anaplastic Astrocytomas
LOH 10q (70%)
DCC Loss (50%)
PDGFRa amplified (10%)
PTEN mutated (10%)
PI3K mutated/amplified (10%)
VEGF overexpressed
Secondary GBM
Wen PY, Kesari S. Malignant Gliomas in Adults. N Engl J Med 2008 359: 492-507
Olig2 expression (100%)
EGFR amplified (40%)
EGFR overexpressed (60%)
EGFR mutated (20%)
MDM2 amplified (10%)
MDM2 overexpressed (>50%)
LOH 10q (70%)
PTEN mutated (40%)
PI3K mutated/amplified (20%)
RB mutated
Low-Grade Oligodendroglioma
VEGF overexpressed
Primary GBM
Olig2 expression (100%)
LOH 1p, 4q, 19q
EGFR overexpressed
PDGF/PDGFR overexpressed
p16 loss
RB mutated (65%)
P53 mutated
PTEN loss
LOH 9p, 10q
CDK4/EGFR/Myc amplified
VEGF overexpressed
Anaplastic Oligodendroglioma
 Angiogenesis is central to GBM

 Driven by VEGF
 Blood vessels in GBM
 Dilated
 Abnormal
 Hyperpermeable

 Restoration of vascular integrity

 Decreases permeability
 Improves oxygen delivery
 Increase chemo-sensitiviy
 Increas radio-sensitivity
 Therapy of Malignant Gliomas

Maximal RT + TMZ, followed by TMZ

Glioblastoma surgical
resection Carmustine wafers + RT

Maximal RT + TMZ, followed by TMZ

Anaplastic astrocytoma surgical
resection TMZ

RT
Anaplastic Oligodendrogliomas Maximal RT + TMZ, followed by TMZ
surgical RT, followed by TMZ
resection PCV +/- RT
TMZ +/- RT
NCCN
 TMZ + RT in GBM

RT

Maximal surgical
resection R

Chemo-RT
Temozolomide (TMZ) 75 mg/m2 every day while on
radiotherapy, followed by single-agent temozolamide
150-200 mg/m2 for 5 days, q28d, for 6 months

Stupp R, Mason WP, van den Bent MJ, et al. the National Cancer Institute of Canada Clinical Trials Group, Radiotherapy plus
Concomitant and Adjuvant Temozolomide for Glioblastoma. N Engl J Med 2005 352: 987-996
 TMZ+RT in GBM

N=573

OS: 14.6 vs 12.1

2-yr S: 26% vs 10

Stupp R, Mason WP, van den Bent MJ, et al. the National Cancer Institute of Canada Clinical Trials Group, Radiotherapy plus
Concomitant and Adjuvant Temozolomide for Glioblastoma. N Engl J Med 2005 352: 987-996
 Silenced MGMT improves survival in GBM

 MGMT (O6-Methylguanine-
DNA-Methyltransferase)
 Removes alkyl groups N=92
 Restores DNA integrity

 Epigenetic silencing of
MGMT
 Frequent in GBM (45%)
 By promoter methylation

 Silenced MGMT results in

 Improves survival
 Chemosensitivity to TMZ

Hegi ME, Diserens AC, Gorlia T, et al. MGMT Gene Silencing and Benefit from
Temozolomide in Glioblastoma. N Engl J Med 2005 352: 997-1003
 Silenced MGMT improves chemo-sensitivity

Hegi ME, Diserens AC, Gorlia T, et al. MGMT Gene Silencing and Benefit from
Temozolomide in Glioblastoma. N Engl J Med 2005 352: 997-1003
 Second-line therapy in GBM

 Only 5% survive >5 years

 6-month progressión-free survival after progression is < 25%
 TMZ: 21%
 No established second-line therapy
 Opportunity for targeted-therapy
 15% 6-month PFS cut-off for “active” strategies
 Second-line therapy in GBM

Wong ET, Hess KR, Gleason MJ, et al. Outcomes and

Prognostic Factors in Recurrent Glioma Patients
Enrolled Onto Phase II Clinical Trials. J Clin Oncol
1999 17: 2572
Targeted therapy in GBM

Slide No. 13
 Ligand
Anti EGFR MoAbs

Anti VEGF PIP2 RTK inhitors anti PDGF Farnesyl-transferase

PI3K
PIP3 inhibitors
PI3K inhibitors
Grb2/mSOS
RTK inhibitors Anti VEGF PDK1 AKT RTK inhibitors anti EGF RAS
mTOR inhibitors mTOR Protein
synthesis Raf & MEK Raf GAP
p70S6k inhibitors
MEK

ECM Activated ERK1/2

Transcription
Cytoskeleton factors AP-1(Jun-Fos)
Serum Response Factor
Integrin FAK
Activated
Integrin Inhibitors c-Src kinases
STAT Cell-Cycle MYC
JAK regulation CiclinaD
Ciclinas/cdks
PKC Nucleus
PLC-γ HDAC inhibitors
Ca2+ Steroid hormone
PIP2 receptors
DAG

Wen PY, Kesari S. Malignant Gliomas in Adults. N Engl J Med 2008 359: 492-507
 Ligand Imatinib
Cetuximab Anti EGFR Dasatinib
Bevacizumab Panitumumab Tandutinib
Afibercept

Farnesyl-transferase
Anti VEGF PIP2 RTK inhitors anti PDGF
PI3K inhibitors
PIP3 PI3K inhibitors
RTK inhibitors Anti VEGF Grb2/mSOS
PDK1 AKT Lonafarnib
BEZ325 RTK inhibitors anti EGF RAS Tipifarnib
Sunitinib mTOR inhibitors mTOR XL765 Protein Gefitinib
Sorafenib Raf
Vandetanib p70S6k synthesis Erlotinib GAP
Temsirolimus
MEK
Cediranib Everolimus Lapatinib
ECM Sirolimus Activated Vandetanib ERK1/2
Transcription
Cytoskeleton factors AP-1(Jun-Fos)
Serum Response Factor
Integrin FAK
Activated
Integrin Inhibitors c-Src kinases
STAT Cell-Cycle MYC
Cilengitide JAK regulation CiclinaD
Ciclinas/cdks
PKC Nucleus
PLC-γ HDAC inhibitors
Ca2+ Steroid hormone
PIP2 receptors Depsipeptide
DAG Vorinostat

Wen PY, Kesari S. Malignant Gliomas in Adults. N Engl J Med 2008 359: 492-507
 Anti-angiogenic therapy of GBM

 Bevacizumab
 Anti VEGF antibody
 Cediranib
 Oral pan VEGF tyrosine kinase inhibitor
 Cilengitide
 Anti integrin agent
Bevacizumab in recurrent malignant gliomas

 Bevacizumab + Irinotecan
 57-63% response rate
 6-month PFS: 46% (vs 21%
with TMZ)
 Combination superior to
single-agent Irinotecan

 Vredenburgh JJ, Desjardins A, Herndon JE II, et

al. Bevacizumab plus irinotecan in recurrent
glioblastoma multiforme. J Clin Oncol
2007;25:4722-4729.
 Bevacizumab in GBM
 Bevacizumab + Irinotecan
 57-63% response rate
 6-month PFS: 46%
 Combination superior to single-
agent Irinotecan

N Engl J Med 2008 359: 492-507

Vredenburgh JJ, Desjardins A, Herndon JE II, et al. Phase II trial of bevacizumab and irinotecan in recurrent malignant glioma.
Clin Cancer Res 2007;13:1253-1259; Vredenburgh JJ, Desjardins A, Herndon JE II, et al. Bevacizumab plus irinotecan in
recurrent glioblastoma multiforme. J Clin Oncol 2007;25:4722-4729. 
 Cediranib in recurrent GBM

 AZD2171
 Pan VEGFR, PDGFRa,
PDGFRb TKI
 Oral
 Median half-life: 12-35 hours
 Dose: 45 mg QD

Wikipedia
 Cediranib in recurrent GBM

 NCI Phase II trial

 31 patients with recurrent GBM
 Daily Cediranib PO
 Primary End-Point: 6 mo – PFS
 Secondary End-Points:
 Radiographic response
 Overall survival
 Toxicity
 Correlative biomarker and imaging studies
Gerstner ER, Duda DG, di Tomaso E, et al. Cediranib, an Oral Pan-VEGF Tyrosine Kinase Inhibitor,
in the Treatment of Glioblastoma. Current Treatment Options in Oncology (2008) 9:1-2
 Cediranib in recurrent GBM

Batchelor TT, Sorensen AG, di Tomaso E, et al. (2007). AZD2171, a pan-VEGF receptor tyrosine kinases inhibitor,
normalizes tumor vasculature and alleviates edema in glioblastoma patients. Cancer Cell 11(1), 83-95; Gerstner ER,
Duda DG, di Tomaso E, et al. Cediranib, an Oral Pan-VEGF Tyrosine Kinase Inhibitor, in the Treatment of
Glioblastoma. Current Treatment Options in Oncology (2008) 9:1-2
 Cediranib in recurrent GBM

 Median PFS: 117 days

 Median OS: 227 days in 31 patients enrolled in the trial, respectively.
 6-month PFS: 26%

 Serial MRI scans:

 Vascular normalization
 Decrease in brain edema
 Steroid-sparing effect

 Toxicity
 Diarrhea
 Hypertension
 Fatigue (2 patients stopped the intervention due to fatigue).
 No intracerebral hemorrhages in any patients.

 Several phase I-II trials have been initiated with cediranib with lomustine in relapsed GBM,
and cediranib plus temozolamide and radiation therapy in newly diagnosed GBMs.

Gerstner ER, Duda DG, di Tomaso E, et al. Cediranib, an Oral Pan-VEGF Tyrosine Kinase Inhibitor,
in the Treatment of Glioblastoma. Current Treatment Options in Oncology (2008) 9:1-2
 Cediranib in recurrent GBM

Batchelor TT, Sorensen AG, di Tomaso E, et al. (2007). AZD2171, a pan-VEGF receptor tyrosine kinases inhibitor,
normalizes tumor vasculature and alleviates edema in glioblastoma patients. Cancer Cell 11(1), 83-95
 Slide No. 23

Integrin v3 expression in glioblastomas

100 µm 100 µm 100 µm

Integrin v3 CD31 Integrin v3/CD31

(endothelial cells) fluorescent overlay

Schnell et al, Brain Pathol 2008

 Cilengitide in GBM

 Mechanismo of action
 Selective alphavbeta3 and
alphavbeta5 integrin antagonist
 Intravenous formulation
 Integrins
 Cell surface receptors
 Endothelial cell proliferation
 Endothelial cell migration

 Blocking the ligation of integrins by

antagonists
 Apoptosis of proliferative
angiogenic cells
 
Wikipedia
 Cilengitide studies in glioblastoma

Cilengitide
first-line
Resectable Study 0101,a
Symptoms

Recurrence
Diagnosis

Cilengitide
Radiation Chemo- second-line
therapy + therapy Study 0092,b

Biopsy
Unresectable

Merck–Serono-sponsored trials:
a
Study 010=EMD 121974–010; bStudy 009=EMD 121974–009

1. Stupp R, et al. Society for Neuro-Oncology, 12th Annual Meeting, Dallas, TX, USA, November 2007, Abstract No. MA-10;
2. Reardon D, et al. Society for Neuro-Oncology, 12th Annual Meeting, Dallas, TX, USA, November 2007, Abstract No. MA-08
 Cilengitide single agent: Study 009

Survival distribution function Cohort to which subject is assigned

500 mg
1.0
2000 mg
0.9
0.8
0.7
2000 mg: median OS 9.9 months
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0 6 12 18 24 30 36 42
Time (months)
 Study design

Concomitant phase Adjuvant phase (6 months)

+ C i l e n g i t i d e (twice weekly IV)

Temozolomide (TMZ) daily x 6

weeks

RT
(30 x 2 Gy)

 TMZ 75 mg/m2 daily (7/7) during RT

 Maintenance 150–200 mg/m2 x 5 days for 6 cycles
 RT 60 Gy (30 x 2 Gy), to start 3–5 weeks post surgery
 Cilengitide 500 mg flat dose twice weekly IV to start 1 week before
TMZ/RT, continue throughout chemoradiotherapy, optional single-agent
maintenance after completion of 6 cycles of TMZ
 Primary endpoint: PFS rate after 6 months of treatment

Stupp R, et al. Society for Neuro-Oncology, 12th Annual Meeting, Dallas, TX, USA, November 2007, Abstract No. MA-10;
Stupp R, et al. J Clin Oncol 2007;25(Suppl. 18S):Abstract No. 2000 (updated information presented)
 Overall survival: ITT population
1.0 n=52
Died 28 (54%)
0.9
0.8
Median OS: 16.1 months
0.7
(95% CI 13–NA)
0.6
Survival

0.5 12-month OS: 64%

(95% CI 49–76)
0.4
0.3
0.2
0.1
0.0
0 2 4 6 8 10 12 14 16 18 20 22 24
Time (months)
Stupp R, et al. Society for Neuro-Oncology, 12th Annual Meeting, Dallas, TX, USA, November 2007, Abstract No. MA-10
 Overall survival according to
MGMT status

1.0
0.9
— Methylated (n=23)
0.8
Median OS:
0.7 not reached
15-month OS: 77.4%
0.6 (95% CI 54–90)
Survival

0.5
— Unmethylated (n=22)
0.4
Median OS:
0.3 13.1 months
(95% CI 9.7–18)
0.2
15-month OS: 41%
0.1 (95% CI 20–61)

0.0
0 2 4 6 8 10 12 14 16 18 20 22 24
Time (months)
Stupp R, et al. Society for Neuro-Oncology, 12th Annual Meeting, Dallas, TX, USA, November 2007, Abstract No. MA-10
 Cilengitide phase III for GBM

Diagnosis

Step 1: Central MGMT methylation status assay

} Registration

MGMT unmethylated MGMT methylated

Step 2: Randomization
} Randomization

+ New agent: to be defined versus control

To be defined R
+ cilengitide

Radiotherapy TMZ

Concomitant phase Adjuvant (maintenance) phase Radiotherapy

Concomitant phase Adjuvant (maintenance) phase

 Conclusions

 TMZ+RT remains one SOC for newly diagnosed GBM

 Promoter methylation of MGMT identifies
alkylator-sensitive disease
 MGMT status not routinely available, though
 Anti angiogenic agents are promising therapeutic
strategies in GBM with favorable 6-mo PFS.
 Aiming at other targets has been disappointing, so
far
 Further studies are needed

Slide No. 32