14507 Background: Bevacizumab (Bv) and other VEGF/VEGFR-targeting agents have become useful therapies for cancer and are active against primary and metastatic central nervous system malignancies (CNSM). Its use in patients with brain metastases, however, has been largely avoided over concerns for precipitating intracerebral hemorrhage (ICH) and also an increased risk of thromboembolic disease. We report here a retrospective analysis of ICH and cerebrovascular infarct (CVA) incidences in CNSM patients who received Bv-based treatment. Methods: Using institutional billing and pharmacy databases we reviewed the electronic records of 149,421 patients treated at the University of Texas M. D. Anderson Cancer Center between 9/1/02 and 8/31/06. CNSM were diagnosed in 6674 patients. The first 13,088 cancer patients without CNSM were analyzed as a control group. The prevalence of CNSM, treatment with Bev, and ICD-9 codes for CVD, cerebral infarcts, and ICH, and their temporal relationships were compared and analyzed by Yates Corrected Chi-square test. Results: 1,360 patients received Bv therapy; of these 179 had CNSM. The prevalence of ICH among those with CNSM whether they receved Bv or not (4.5% vs 4.4%, p=0.887). Prior radiotherapy had been given to 4 of 8 patients who developed ICH after Bv treatment. In Bev-treated patients, ICH prevalence was higher in those with CNSM than in those without (4.5% vs 0.9%, p=0.0006). In those not receiving Bv, ICH prevalence was lower in those with CNSM than in those without (4.4% vs 5.8%, p<0.0001). The prevalence of CVA was increased in CNSM by Bv treatment (0.5% to 1.7%, p=0.095). In non-CNSM patients, Bv treatment compared to no Bv treatment was associated with lower CVA prevalence (0.1% vs 1.6%, HR 0.06, p=0,0001) and lower ICH prevalence (0.9% vs. 5.8%, HR 0.16, p<0.0001). Conclusions: In CNSM patients treatment with Bv does not appear to increase the risk of ICH, and despite an increase in CVA prevalence, the risk was not statistically significant. Bv-based therapy carries no appreciable increase in cerebrovascular risk in patients with CNSM. In patients without CNSM, those selected for Bv therapy had markedly lower cerebrovascular risk than those who were not. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Expert Testimony Other Remuneration Genentech Genentech Genentech

Targeted drug delivery aims to increase the therapeutic index by making more drug molecules available at the diseased sites while reducing systemic drug exposure. In this update, we provide an overview of polymer-drug conjugates that have advanced into clinical trials. These systems use synthetic water-soluble polymers as the drug carriers. The preclinical pharmacology and recent data in clinical trials with poly(l-glutamic acid)-paclitaxel (PG-TXL) are discussed. This is followed by a summary of a variety of polymeric conjugates with chemotherapeutic agents. Results from early clinical trials of these polymer-drug conjugates have demonstrated several advantages over the corresponding parent drugs, including fewer side effects, enhanced therapeutic efficacy, ease of drug administration, and improved patient compliance. Collectively, these data warrant further clinical development of polymer-drug conjugates as a new class of anticancer agents.

To determine whether a polymer-drug conjugate might improve tumor cell kill compared to the corresponding unconjugated agent when used in combination with radiation, we examined the antitumor activity of a water-soluble conjugate of N-(4-hydroxyphenyl) retinamide (4HPR) and poly(L-glutamic acid), PG-4HPR, in lung cancer cells and xenografts. The antiproliferative activity of 4HPR and PG-4HPR in human lung cancer A549 cells was evaluated and the response of the cells to radiation measured by clonogenic assay. Response to irradiation was evaluated by measuring tumor growth delay in nude mice bearing intramuscularly inoculated A549 tumors. Histologic responses were assessed by examination of apoptosis (TUNEL assay) and cell proliferation (Ki67 staining). In vitro, 4HPR and PG-4HPR inhibited the proliferation of A549 cells, with IC50 values of 25.8 microM and >50 microM, respectively, after 24 h of continuous exposure and 6.25 microM and 9.75 microM, respectively, after 120 h. Both agents increased radiosensitivity at an equivalent 4HPR concentration of 10 microM after 5 days of exposure, with enhancement factors of 1.40 and 1.43. In tumor xenografts, intravenous injection of 4HPR or PG-4HPR (30 mg eq. 4HPR/kg) enhanced radiosensitivity by 1.3 and 1.6, respectively, without apparent systemic toxicity. PG-4HPR augmented radiation-induced apoptosis and decreased cellular proliferation in vivo. The radiation response of A549 tumors was greater with PG-4HPR than with 4HPR, which may be attributed to increased delivery of 4HPR to the tumors and enhanced apoptotic response. These results suggest that a polymeric delivery system may be useful for modulating radiosensitivity.

Most anti-cancer chemotherapeutic drugs used clinically are limited by a relatively low therapeutic index, owing to toxic side effects. This chapter presents the applications of poly(l-glutamic acid) (PG) in the delivery of both chemotherapeutic and diagnostic agents. PG is an effective solubilizing carrier of camptothecin (CPT) and serves to protect the E-ring lactone structure in CPT. Studies have systematically investigated the structural effects of the anti-tumor efficacy of CPT, including linkers between PG and CPT, the point of attachment of PG on the CPT molecule, the polymer molecular weight, and drug loading. Many chemotherapeutic agents can increase the radiosensitivity of tumors, potentiating the tumor response to radiation-caused damage. Near-infrared optical imaging has unique advantages for diagnostic imaging of solid tumors. The linkage of polymer–drug conjugates is important to the in vivo release of a drug that should be stable during circulation but should also allow drug release at an appropriate rate at the tumor tissue.

UNLABELLED:99mTc-Labeled annexin V has been used for the imaging of tumor apoptosis induced by chemotherapy. However, owing to the short half-life of annexin V, multiple injections of the radiotracer are necessary to capture the peak apoptotic activity. In this study, we evaluated the imaging properties of an (111)In-labeled, long-circulating annexin V.METHODS:Both polyethylene glycol (PEG) and the metal chelator diethylenetriaminepentaacetic acid (DTPA) were simultaneously introduced to annexin V or ovalbumin through the use of a heterofunctional PEG precursor. Imaging studies were performed in mice bearing subcutaneously inoculated human mammary MDA-MB-468 tumors. The mice were treated with poly(L-glutamic acid)-paclitaxel, monoclonal antibody C225, or a combination of poly(L-glutamic acid)-paclitaxel and C225, followed by intravenous injection of (111)In-DTPA-PEG-annexin V. Images were acquired 48 h after the injection of the radiotracer. Autoradiography and TUNEL (terminal deoxynucleotidyltransferase-mediated dUTP nick-end labeling) staining were performed on adjacent tumor slices for the localization of apoptotic cells. The imaging properties of unPEGylated annexin V and PEGylated ovalbumin were also determined to permit assessment of the specificity of (111)In-DTPA-PEG-annexin V.RESULTS:Tumor apoptotic index increased from 1.67% +/- 0.31% at baseline to 7.60% +/- 0.72% and 11.07% +/- 1.81%, respectively, 4 d after treatment with poly(L-glutamic acid)-paclitaxel or combined poly(L-glutamic acid)-paclitaxel and C225. Tumor uptake (percentage of injected dose per gram of tumor [%ID/g]) of PEGylated (111)In-DTPA-PEG-annexin 4 d after treatment was significantly higher in tumors treated with poly(L-glutamic acid)-paclitaxel (10.76 +/- 1.38 %ID/g; P = 0.001) and with combined poly(L-glutamic acid)-paclitaxel and C225 (9.84 +/- 2.51 %ID/g; P = 0.029) than in nontreated tumors (6.14 +/- 0.67 %ID/g), resulting in enhanced visualization of treated tumors. (111)In-DTPA-PEG-annexin V distributed into the central zone of tumors, whereas (111)In-DTPA-annexin V was largely confined to the tumor periphery. Furthermore, uptake of (111)In-DTPA-PEG-annexin V by tumors correlated with apoptotic index (r = 0.87, P = 0.02). Increase in tumor uptake of the nonspecific PEGylated protein (111)In-DTPA-PEG-ovalbumin was also observed after poly(L-glutamic acid)-paclitaxel treatment (55.6%), although this increase was less than that observed for (111)In-DTPA-PEG-annexin V (96.7%).CONCLUSION:Increased uptake of and improved visualization with (111)In-DTPA-PEG-annexin V in solid tumors after chemotherapy are mediated through both specific binding to apoptotic cells and nonspecific retention of macromolecular contrast agents in the tumors. (111)In-Labeled, PEGylated annexin V may be used to assess tumor response to chemotherapy.

Most currently evaluated macromolecular contrast agents for magnetic resonance imaging (MRI) are not biodegradable. The goal of this study is to synthesize and characterize poly(l-glutamic acid) (PG) gadolinium chelates as biodegradable blood-pool MRI contrast agents. Two PG chelates of gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA) were synthesized through the use of difunctional and monofunctional DTPA precursors. The conjugates were characterized with regard to molecular weight and molecular weight distribution, gadolinium content, relaxivity, and degradability. Distributions of the polymeric MRI contrast agents in various organs were determined by intravenous injection of (111)In-labeled polymers into mice bearing murine breast tumors. MRI scans were performed at 1.5 T in mice after bolus injection of the polymeric chelates. PG-Hex-DTPA-Gd, obtained from aminohexyl-substituted PG and DTPA-dianhydride, was partially cross-linked and was undegradable in the presence of cathepsin B. On the other hand, PG-Bz-DTPA-Gd synthesized directly from PG and monofunctional p-aminobenzyl-DTPA(acetic acid-tert-butyl ester) was a linear polymer and was degradable. The relaxivities of the polymers at 1.5 T were 3-8 times as great as that of Gd-DTPA. Both polymers had high blood concentrations and were primarily accumulated in the kidney. However, PG-Bz-DTPA-Gd was gradually cleared from the body and had significantly less retention in the blood, the spleen, and the kidney. MRI with PG-Bz-DTPA-Gd in mice showed enhanced vascular contrast at up to 2 h after the contrast agent injection. The ability of PG-Bz-DTPA-Gd to be degraded and cleared from the body makes it a favorable macromolecular MRI contrast agent.

M@C(60) and related endohedral metallofullerenes comprise a significant portion of the metallofullerene yield in the traditional arc synthesis, but their chemistry and potential applications have been largely overlooked because of their sparse solubility. In this work, procedures are described to solublize Gd@C(60) species for the first time by forming the derivative, Gd@C(60)[C(COOCH(2)CH(3))(2)](10), and its hydrolyzed water-soluble form, Gd@C(60)[C(COOH)(2)](10). Imparting water solubility to Gd@C(60) permits its evaluation as a magnetic resonance imaging (MRI) contrast agent. Relaxometry measurements for Gd@C(60)[C(COOH)(2)](10) reveal it to possess a relaxivity (4.6 mM(-1) s(-1) at 20 MHz and 40 degrees C) comparable to that of commercially available Gd(III) chelate-based MRI agents. An in vivo MRI biodistribution study in a rodent model reveals Gd@C(60)[C(COOH)(2)](10) to possess the first non-reticuloendothelial system (RES) localizing behavior for a water-soluble endohedral metallofullerene species, consistent with its lack of intermolecular aggregation in solution as determined by light-scattering measurements. This first derivatization and use of a M@C(60) species suggests new potential for metallofullerene technologies by reducing reliance on the chromatographic purification procedures normally employed for the far less abundant M@C(82) and related endohedrals. The recognition that water-soluble fullerene derivatives can be designed to avoid high levels of RES uptake is an important step toward fullerene-based pharmaceutical development.

Purpose. Targeted delivery of chemotherapeutic agents through antibody-polymer conjugates has met with limited success. One of the limiting factors is the loss of antibody's binding affinity upon conjugation with polymeric carriers because of lack of control over the number and site of attachment. This study aims to synthesize monovalent polymeric immunoconjugates through site-specific conjugation and to evaluate the in vitro binding activities of the resulting construct.Methods. Antibody C225 against epidermal growth factor receptors was coupled to the terminus of a doxorubicin-bound block copolymer, poly(L-glutamic acid)-co-polyethylene glycol (PG-PEG). Western blot analysis, confocal fluorescent microscopy, and cytotoxicity assay were performed to confirm the specific binding of C225-PEG-PG-Dox to EGFR.Results. C225 was conjugated to PEG-PG-doxorubicin conjugates by reacting sulfhydryl group introduced to C225 with vinylsulfone group introduced at the terminus of PEG-PG block copolymer. Polymeric immunoconjugate C225-PEG-PG-Dox, but not control (i.e., conjugate without antibody), selectively bound to human vulvar squamous carcinoma A431 cells that overexpress epidermal growth factor receptors. Receptor-mediated uptake of C225-PEG-PG-Dox occurred rapidly (within 5 min), whereas nonspecific uptake of PEG-PG-Dox required an extended period of time ( 24 h) to internalize. Binding of C225-PEG-PG-Dox to A431 cells could be blocked by pretreatment with C225 antibody. C225-PEG-PG-Dox was more potent than free doxrubicin in inhibiting the growth of A431 cells after a 6-h exposure period.Conclusion. Site-specific conjugation of a monoclonal antibody to the terminus of a polymeric carrier enhances receptor-mediated delivery of anticancer agents.

Purpose: Conjugating drugs with polymeric carriers is one way to improve selective defivery to tumors. Poly (L-glutamic acid)-paclitaxel (PG-TXL) is one such conjugate. Compared with paclitaxel, its uptake, tumor retention, and antitumor efficacy are increased. Initial studies showed that PG-TXL given 24 h before or after radiotherapy enhanced tumor growth delay significantly more than paclitaxel. To determine if PG-TXL-induced enhancement is obtained in a more clinically relevant setting, we investigated PG-TXL effects on tumor cure.Methods and Materials: Mice bearing 7-mm-diameter ovarian carcinomas were treated with PG-TXL at an equivalent paclitaxel dose of 80 mg/kg, single dose or 5 daily fractions of radiation or both PG-TXL and radiation. Treatment endpoint was TCD50 (radiation dose yielding tumor control in 50% of mice). Acute radioresponse of jejunum, skin, and hair was determined for all treatments.Results: PG-TXL dramatically improved tumor radioresponse, reducing TCD50 of single-dose irradiation from 53.9 (52.2-55.5) Gy to 7.5 (4.5-10.7) Gy, an enhancement factor (EF) of 7.2. The drug improved the efficacy of fractionated irradiation even more, reducing the TCD50 of 66.6 (62.8-90.4) Gy total fractionated dose to only 7.9 (4.3-11.5) Gy, for an EF of 8.4. PG-TXL did not affect normal tissue radioresponse resulting from either single or fractionated irradiation.Conclusion: PG-TXL dramatically potentiated tumor radiocurability after single-dose or fractionated irradiation without affecting acute normal tissue injury. To our knowledge, PG-TXL increased the therapeutic ratio of radiotherapy more than that previously reported for other taxanes, thus, PG-TXL has a high potential to improve clinical radiotherapy. (C) 2003 Elsevier Science Inc.

We have developed a one-step procedure to introduce both polyethylene glycol (PEG) and the metal chelator diethylenetriaminepentaacetic acid (DTPA) to proteins through a heterofunctional PEG precursor. The PEG precursor contains DTPA at one end and an amine-reactive isothiocyanate (SCN-) functional group at the other end. It was obtained as lyophilized powder and could be stored at 4 degrees C for several months. Protein conjugation was achieved by simply mixing the proteins and the PEG precursor SCN-PEG-DTPA in an aqueous solution. As exemplified by the PEGylation and radiolabeling of annexin V, the resulting conjugate 111In-DTPA-PEG-annexin V showed selective binding to apoptotic cells in vitro and increased blood half-life in vivo. The PEGylated, radiolabeled annexin V may be useful in the noninvasive imaging of apoptosis.

The specificity of a novel epidermal growth factor (EGF)-Cy5.5 fluorescent optical probe in the detection of EGF receptor (EGFr) was assessed using continuous-wave fluorescence imaging accomplished via an intensified charge-coupled device (CCD) camera. Human mammary MDA-MB-468 (EGFr+) and MDA-MB-435 (EGFr-) cancer cells were incubated with Cy5.5, EGF-Cy5.5, or the anti-EGFr monoclonal antibody C225 or EGF followed by EGF-Cy5.5 and examined under a fluorescence microscope. In vivo imaging was performed on mice with s.c. MDA-MB-468 and MDA-MB-435 tumors. Images were obtained every 6 s for 20 min after i.v. injection of each agent and every 24 h after injection for up to 192 h. Additionally, mice with MDA-MB-468 tumors were injected i.v. with C225 24 h before injection of EGF-Cy5.5. EGF-Cy5.5, but not Cy5.5 or indocyanine green dye (ICG), bound to MDA-MB-468 cells. Binding of EGF-Cy5.5 was blocked by C225 and by EGF. In contrast, binding of EGF-Cy5.5 to MDA-MB-435 cells was not observed. Monitoring of the time-fluorescence intensity in mice confirmed that ICG and Cy5.5 had no favorable binding to tumor regardless of EGFr expression level. In contrast, EGF-Cy5.5 accumulated only in MDA-MB-468 tumors. Moreover, tumor uptake of EGF-Cy5.5 was blocked by C225. ICG and Cy5.5 fluorescence was completely absent from the tumor site, regardless of EGFr expression level, 24 h after injection. Little EGF-Cy5.5 fluorescence was detected in MDA-MB-435 tumors 24 h after injection. In MDA-MB-468 tumors, our data suggest that EGF-Cy5.5 may be used as a specific NIR contrast agent for noninvasive imaging of EGFr expression and monitoring of responses to molecularly targeted therapy.

BACKGROUND. Giant cell tumors of the bone can behave as aggressive and sometimes lethal tumors. In the sacrum, the tumor can be extremely difficult to manage. Standard treatments, including surgery and radiation, are associated with significant complications and recurrence rates. The goal of this study is to evaluate the long-term outcome of selective arterial embolization as an alternative treatment modality.METHODS. From 1975 to 2001, 18 patients were treated with selective intraarterial embolization. The embolization method was a combination of Gelfoam particles and coils for peripheral and central occlusions, respectively. The number of embolizations was based on clinical symptoms, radiographic response, and the vascularity of the tumor. Nine patients received intraarterial cisplatin as part of their treatment. The median follow-up was 105 months.RESULTS. Of 18 patients, 14 responded favorably to embolization with improvement in pain and neurologic symptoms. Computed tomographic and magnetic resonance imaging scans showed reossification and stabilization of tumor size. Arteriograms showed diminished vascularity. With long-term follow-up, three patients developed late disease recurrences within the sacrum. Kaplan-Meier analysis showed that the risk of local recurrence is 31% at 10 years and 43% at 15 and 20 years. The long-term outcome was not affected by intraarterial cisplatin. There was one death that occurred 1 day after embolization.CONCLUSIONS. Most patients demonstrate an objective early radiographic response to embolization. Long-term follow-up shows that the response is durable in approximately one half of the patients. Given the potential morbidity of other treatments, embolization should be included in the armamentarium of treatment for this difficult disease. Embolization may be used alone or in conjunction with other therapy. Long-term follow-up is recommended for all patients because late disease recurrence or sarcomatous change can occur. (C) 2002 American Cancer Society.