Ulllted States Patent [19]
`Andrulis, Jr. et al.
`
`US006140346A
`[11] Patent Number:
`[45] Date of Patent:
`
`6,140,346
`Oct. 31, 2000
`
`[54] TREATMENT OF CANCER WITH
`THALIDOMIDE ALONE OR IN
`COMBINATION WITH OTHER
`ANTI-CANCER AGENTS
`
`[58] Field of Search ................................... .. 514/323, 105,
`514/492, 561, 564, 672; 424/649
`_
`References Wed
`
`[5 6]
`
`[75] Inventors: Peter J. Andrulis, J r., Bethesda;
`Murray W. Drulak, Gaithersburg, both
`of Md‘
`
`5,399,363
`
`U'S' PATENT DOCUMENTS
`3/1995 Liversidge et al. ................... .. 424/490
`OTHER PUBLICATIONS
`
`[73] Assignee? Andrulis Pharmaceuticals Carp»
`Bethesda, Md.
`
`Nguyen et al., Int. J. Oncol., 10(5), 965—969 Abstract Only,
`1997_
`
`_
`[21] Appl' NO" 09/071’813
`[22] Filed:
`May 4, 1998
`
`Primary Examiner—Jerome D. Goldberg
`Attorney, Agent, or Firm—Isaac Angres
`[57]
`ABSTRACT
`
`[51]
`
`Related US‘ Application Data
`_
`_
`_
`_
`63
`[
`] $352121“ of apphcanon NO‘ 08/471353’ Jun‘ 6’ 1995’
`'
`IIlt- Cl-7 ---------------------- -- A61K 31/445; A61K 31/66;
`A61K 31/28; A61K 31/ 195; A61K 31/13;
`A61K 33/24
`[52] US. Cl. ........................ .. 514/323; 514/105; 514/492;
`514/561; 514/564; 514/672; 424/649
`
`A method is provided for the treatment of neoplastic dis
`eases in a mammal Which comprises administering to said
`mammal a therapeutically effective amount of thalidomide.
`The method also uses a combination of thalidomide With
`other anti-neoplastic agents. Additionally, pharmaceutical
`compositions containing thalidomide and other anti-cancer
`agents are also provided.
`
`3 Claims, N0 Drawings
`
`DR. REDDY’S LABS., INC. EX. 1040 PAGE 1
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`

`

`6,140,346
`
`1
`TREATMENT OF CANCER WITH
`THALIDOMIDE ALONE OR IN
`COMBINATION WITH OTHER
`ANTI-CANCER AGENTS
`
`This application is a continuation of Ser. No. 08/471,353,
`?led Jun. 6, 1995, noW abandoned.
`The present invention relates to a novel method for
`treating cancers With thalidomide alone or in combination
`With other antiangiogenic and anti-cancer agents. The
`present invention also relates to methods of treating cancers
`With cytokine/groWth factor inhibitors such as those agents
`inhibitory to basic ?broblast groWth factor (bFGF), Tumor
`Necrosis Factor alpha (TNF-alpha), and interleukin 1 beta
`(IL-1 beta) and other antiangiogenic agents as Well as
`pharmaceutical compositions containing thalidomide and/or
`other antiangiogenesis agents and/or anticancer drugs.
`The present invention further relates to a method for
`ameliorating the symptoms of neoplastic diseases by admin
`istering thalidomide alone or in combination With other
`anti-neoplastic drugs.
`The instant invention also relates to a method for inhib
`iting establishment of neoplastic metastasis by administer
`ing thalidomide alone or in combination With other anti
`neoplastic drugs.
`
`BACKGROUND OF THE INVENTION
`
`Cancer is second only to cardiovascular disease as a cause
`of death in the United States. One third of all individuals in
`the United States Will develop cancer and 20% of Americans
`Will die of the disease. In the United States in 1992 there
`Were 26,000 deaths due to malignancies and, of these, half
`of the deaths Were due to the three most common types of
`cancer lung, breast and colon.
`Further, cancer is de?ned as an abnormal groWth of tissue
`characteriZed by a loss of cellular differentiation. This term
`encompasses a large group of diseases in Which there is an
`invasive spread of such undifferentiated cells from a primary
`site to other parts of the body Where further undifferentiated
`cellular replication occurs, Which eventually interferes With
`the normal functioning of tissues and organs. According to
`Harrison’s Principles of Internal Medicine, 13th Edition
`(McGraW Hill NY, Chap. 317—318, 1994), the terms cancer,
`neoplasia and malignancy are often used interchangeably in
`both lay and professional publications.
`Cancer is de?ned by four characteristics Which differen
`tiate neoplastic cells from normal ones:
`(1) Clonality—Cancer starts from genetic changes in a
`single cell Which multiplies to form a clone of neo
`plastic cells;
`(2) Autonomy—Biochemical and physical factors that
`normally regulate cell groWth, do not do so in the case
`of neoplastic cells;
`(3) Anaplasia—Neoplastic cells lack normal differentia
`tion Which occurs in nonmalignant cells of that tissue
`type;
`(4) Metastasis—Neoplastic cells groW in an unregulated
`fashion and spread to other parts of the body.
`Each cancer is characteriZed by the site, nature and
`clinical cause of undifferentiated cellular proliferation. The
`underlying mechanism for the initiation of cancer is incom
`pletely understood; hoWever, 80% of cancers are believed to
`be triggered by external stimuli such as exposure to certain
`chemicals, tobacco smoke, UV rays, ioniZing radiation and
`viruses. Development of cancer in immunosuppressed indi
`viduals indicates the immune system is an important factor
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`controlling the replication and spread of cancerous cells
`throughout the body.
`The high incidence of cancer in certain families, though,
`suggests a genetic disposition toWards development of can
`cer. The molecular mechanisms involved in such genetic
`dispositions fall into a number of classes including those that
`involve oncogenes and suppressor genes (Vogelstein, et al.,
`Cell, 70:523, 1992).
`Proto-oncogenes are genes that code for groWth promot
`ing factors necessary for normal cellular replication. Due to
`mutation, such proto-oncogenes are inappropriately
`expressed—and are then termed oncogenes. Oncogenes can
`be involved in malignant transformation of the cell by
`stimulating uncontrolled multiplication.
`Suppressor genes normally act by controlling cellular
`proliferation through a number of mechanisms including
`binding transcription factors important to this process.
`Mutations or deletions in such genes contribute to malignant
`transformation of a cell. Examples of suppressor genes
`include p53 on chromosome 17, Which enables a cell to
`repair damaged DNA, and DCC on chromosome 18, Which
`normally appears on colon cells enabling them to stick
`together but is deleted in cancerous colon cells (Cavenee and
`White, Scienti?c American, 272:72—9, 1995).
`Malignant transformation develops and cancer results
`because cells of a single lineage accumulate defects in
`certain genes such as proto-oncogenes and suppressor genes
`responsible for regulating cellular proliferation. Anumber of
`such speci?c mutations and/or deletions must occur in a
`given cell for initiation of uncontrolled replication. It is
`believed that genetic predisposition to a certain type of
`cancer results from inheritance of genes that already have a
`number of mutations in such key regulatory genes and
`subsequent exposure to environmental carcinogens causes
`enough additional key mutations or deletions in these genes
`in a given cell to result in malignant transformation (NoWell
`et al., Science, 194:23—8, 1976). Changes in other types of
`genes could further the ability of tumors to groW, invade
`local tissue and establish metastases at distant body sites.
`Cancers can produce clinical symptoms in three general
`Ways:
`1) Obliteration of normal tissues With concomitant inter
`ference With normal tissue function, as cancerous cells
`proliferate. This local expansion of cancerous tissue
`can result in pain due to pressure on or stretching of
`nerve ?bers;
`2) Excessive or inappropriate production of biologically
`active agents by cancerous cells such as cytokines or
`hormones. This can result in clinical illness. Such
`agents are important because they may serve as mark
`ers for a certain tumor type, may produce symptoms
`themselves and may serve to promote direct tumor
`groWth;
`3) Psychological effects upon the patient.
`Early detection of cancer by the clinician depends on his
`aWareness of the patient’s family history With respect to
`different types of cancer, possible exposure of the patient to
`environmental factors that cause cancer combined With
`manifestation of any of the seven common Warning signs of
`cancer:
`1) change in boWel or bladder habits;
`2) a sore that does not heal;
`3) unusual bleeding or discharge;
`4) thickening or lumps in the breast or elseWhere;
`5) obvious change in a Wart or mole;
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`3
`6) nagging cough or hoarseness;
`7) indigestion or dif?culty in swallowing.
`The diagnosis of cancer is primarily made by histologic
`and cytologic examination of tumor specimens to exclude
`benign tumors, hyperplasia and in?ammatory processes.
`After a diagnosis of cancer is made, the description of the
`malignancy should include three characteristics that classify
`the neoplasm, yield information important to prognosis and,
`together With determining the anatomic extent of tumors
`(staging), help select optimal therapy:
`1) Tissue of origin of the cancer;
`2) Anatomic origin of the cancer;
`3) Degree of cellular differentiation of the tumor.
`With most solid tumors, it is the metastatic encroachment
`of the tumor on ohter vital function that causes the demise
`of the patient. Approximately 30—40% of patients at initial
`diagnois have metastatic disease; once this occurs, there is
`a relentless progression of the disease. Invasion is a prereq
`uisite for migrationof tumor cells in connective tissue stroma
`and baseement membranes form the major physical barriers
`to the migration process.
`This local extracellular matrix (ECM) invasion is the
`initial event in the development of metastasis although the
`rate limiting step in the often prolonged natural history of
`tumor metastasis is unknoWn. The sequential biochemical
`mechanism ?rst invovles cell attachment to speci?c com
`ponents of ECM folloWed by progressive protolytic disso
`lution.
`The signaling pathWays that intiate tumor cell migdration
`are mong the least understood aspects of invasion and
`metastasis, but are believed to result from speci?c ligand
`receptor interactions. Phospholipase A2 (PLA2) is akey
`membrane signaling enZyme that modulates the level of
`available arachidonic acid, the substrate required for the
`production of eicosanoids (e.g., prostaglandin’s
`leukotrienes, and thromboxanes). These pro-in?ammatory
`mediators have been implicated as initiators of metastasis in
`primary neoplastic tissue. Inhibition of PLA2 has been
`suggested as a novel means to control chronic in?ammation
`associated With tumor progression.
`Cancer therapy is currently divided into ?ve subspecial
`ties: (1) surgery, (2) radiation therapy, (3) chemotherapy, (4)
`immunotherapy, and (5) anti-angiogenic therapy.
`Surgery Was the ?rst and, in a number of cases, still the
`only effective therapy in many of the common solid tumors.
`HoWever, surgery alone has been proven to be effective in
`treating only 25% of tumors. Most often surgery is used as
`a means of reducing the siZe of a tumor and is used in
`combination With other therapeutic approaches.
`Radiation therapy acts by delivering ioniZing electromag
`netic radiation to a tumor site. Electromagnetic radiation,
`termed external beam radiation, is delivered externally to a
`body site from an outside source, While in bradytherapy
`radiation is delivered by insertion of radioactive materials
`Within the body at the site of the tumor.
`In radiation-induced cell death, reactive oxygen interme
`diates and free radicals are produced by exposure to the
`radiation. The utility of radiation depends on the inherent
`radiosensitivity of a given tumor versus adjacent normal
`tissue With the presence of oxygen in the tumor being an
`important determinant of radiosensitivity. Oxygen free radi
`cals produced from the oxygen in the tumor by exposure to
`radiation damages cellular components, especially DNA.
`Radiation therapy has both short and long-term sequelae.
`Acute sequelae are self limited and include erythema and
`desquamation of skin; anemia, myelosuppression and gas
`trointestinal upset. Long-term sequelae can be progressive
`and include myelitis, pericarditis, stenoses, hepatitis, and
`nephropathy.
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`At the moment, chemotherapy is the primary treatment
`used for disseminated malignant disease. Often the tumor
`burden is initially reduced by surgery folloWed by chemo
`therapy Whose goal it is to eliminate the undetectable
`micrometastasis Which remain. Death of malignant cells by
`chemotherapy is dependent on the exposure time to the
`chemotherapeutic agent and its concentration, both of Which
`are limited due to toxicity. In combination therapy, agents
`should have different mechanisms of action on tumor cells
`to complement each other and prevent resistance from
`developing. The folloWing are a number of different groups
`of chemotherapeutic agents Which are used alone or in
`combination to treat various cancers:
`1) Antimetabolites: compounds that induce cytotoxicity in
`tumor cells by being false substrates in biochemical
`pathWays Which results in interference With important
`cellular functions. Examples include aminopterin,
`hydroxyurea, methotrexate, pyrimidine analogue anti
`metabolites such as ?uorouracil and cytarabine, and
`purine analogue antimetabolites such as six
`mercaptopurine, ?udarabine, pentostatin and chlorode
`oxyadenosine. High dosages of these drugs may be
`associated With acute renal damage, hepatotoxicity and
`gastrointestinal toxicity.
`2) Plant alkaloids: vinca alkaloids such as vincristine and
`vinbiastine; the taxanes such as taxol; and the epipodo
`phyllotoxins such as etoposide and teniposide. These
`substances may induce neurotoxicity, bone marroW
`hyperplasia and hypersensitivity reactions.
`3) Anti-tumor antibiotics: anthracyclines such as
`doxorubicin, daunorubicin, idarubicin, and epirubicin;
`anthracenediones such as mitoxantone; cytotoxic gly
`copeptides such as bleomycin, mitomycin and dactino
`mycin. This group of compounds has been demon
`strated to induce cardiomyopathy, tissue extravasation,
`chronic interstitial pneumonitis, renal failure, gas
`trointestinal toxicity and myelosuppression.
`4) Alkylating agents: compounds that inhibit DNA syn
`thesis by forming covalent bonds With nucleic acids.
`This group includes mechlorethamine,
`cyclophosphamide, ifosamide, melphalan,
`chlorambucil, busulfan, and thiotepa as Well as nitro
`surea alkylating agents such as carmustine and lomus
`tine and platinum compound alkylating agents such as
`cisplatin and carboplatin. The most common dose
`limiting toxicity of these compounds is myelosupppres
`sion. Alkylating agents have also been knoWn to induce
`secondary leukemias, neurotoxicity, myocardial necro
`sis and nephrotoxicity;
`5) Endocrine therapy: adrenocorticosteroids such as
`prednisone, methylprednisone and dexamethasone;
`androgens such as ?uoxymesterone; anti-androgens
`such as ?utamide; estrogens such as diethylstilbestrol
`and ethinyl estradiol; anti-estrogens such as tamoxifen;
`progestins such as medroxyprogesterone and megastrol
`acetate; aromatase inhibitors such as aminoglutethim
`ide; gonadotropin-releasing hormone agonists such as
`leuprolide and somatostatin analogues such as oct
`reotide. Endocrine therapy maybe accompanied by
`neurotoxicity, metabolic derangements such as
`hyperglycemia, hypokalemia, ?uid retention,
`hepatotoxicity, impotence, amenorrhea, nausea and
`maculopapular rash;
`6) Other agents: dacarbaZine, procarbaZine and
`L-asparaginase.
`Drug resistance exhibited by tumors is the most important
`cause of treatment failures. Such resistance is either de novo
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`6,140,346
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`5
`in nature Where tumors are inherently resistant to
`chemotherapy, or acquired, upon exposure to a chemothera
`peutic agent. In the later instance, a tumor undergoes further
`spontaneous mutations resulting in a population of geneti
`cally heterogeneous cells as it groWs from a single malig
`nantly transformed cell. This heterogeneity applies to the
`extent individual cells in the tumor are susceptible to the
`chemotherapeutic agent as Well. Treatment With a given
`agent Will eliminate all the susceptible cells from the tumor
`and select for those cells that are resistant to the agent. To
`maximize success in treating such tumors it is important to
`initially reduce the tumor siZe by surgery and then use
`combination chemotherapy involving agents With distinctly
`different mechanisms of action.
`Another facet of this combination approach to cancer
`therapy that may produce an ansWer to this issue of drug
`resistance is immunotherapy. The basic assumption here is
`that since tumor cells have antigens unique to the tumor on
`their surface, it may be possible to assist the host’s immune
`system to more effectively respond to them and thereby
`destroy the cancer. Anumber of approaches have been used.
`For example, attempts have been made by a number of
`investigators to increase the antigen-speci?c immune
`response to the tumor by immuniZing the host With cells
`originally taken from his tumor along With BCG. Hoover
`and Hanna (Semin. Surg. Oncol., 5 :436—440, 1989) reported
`that such a vaccine had a therapeutic effect in the treatment
`of colon cancer.
`Cytokines such as interferon or interleukin 2 (IL-2) alone
`or With lymphokine-activated killer cells have been used as
`cancer therapeutics. Interferon-alpha has proven to be effec
`tive in treating hairy cell leukemia (Golomb et al.,
`Hematology, 4thd ed., NY McGraW Hill, pgs. 1025—30,
`1990, Quesada et al., N. E. J. M., 310:15—18, 1984) and for
`AIDS-associated Kaposi’s Sarcoma (Real et al., J. Clin.
`Oncol., 4:544—551, 1986). IL-2 has been used in vitro to
`stimulate and develop natural killer cells taken from a cancer
`patient. Such cells are then reinfused back into the patient
`and have acted as an effective cancer therapy in renal cell
`carcinoma and melanoma (Greenberg, Adv. Immunol,
`49:281—355, 1991; Yabro, Semin. Surg. Oncol., 7:183—191,
`1991). It is believed that IL-2 stimulates interferon gamma
`production, Which in turn, induces genes that code for major
`histocompatibility class I and class II antigens that are
`essential for tumor antigen presentation leading to an
`adequate immune response (Janik, from Clinical Applica
`tions of Cytokines J. J. Oppenheim et al Editors, Oxford
`Univ. Press, NY, 1993). Another approach employing cytok
`ines as anticancer therapeutics involves delivering cytokines
`continuously to the tumor by transfecting tumor cells in vitro
`With genes that code for cytokines so they can produce these
`cytokines When reinfused back into the patient. Tepper et al.
`(Cell, 57:503—12, 1989) studied the introduction of the IL-4
`gene into several tumor cell types. The problem
`encountered, hoWever, Was that many cytokine-producing
`cells failed to groW When infused into animals. HoWever,
`Golumbek et al. (Science, 254:713—6, 1991) shoWed that
`tumor cells expressing IL-4 Were able to cause tumor
`regression in animals, thereby validating this approach.
`Kedar and Klein (Adv. Cancer Res., 59:245—322, 1992)
`modi?ed this approach by obtaining T cells that had in?l
`trated a tumor, exposing them to IL-2 in vitro, and reinfusing
`them into the same patient. Although this approach has
`shoWn promise, it is limited by difficulties in obtaining and
`expanding the cytotoxic T cell populations needed. Cytokine
`therapy in general has not been as effective as hoped for in
`the treatment of cancer because under natural conditions
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`cytokines are produced and act in synchrony With one
`another; to administer one cytokine in high doses upsets the
`natural balance and can result in many unforeseen effects on
`other cytokines and more generally the host (Janik, from
`Clinical Applications of Cytokines J. J. Oppenheim et al
`Editors Oxford Univ. Press, NY, 1993).
`The difficulty in Working With cytokines is that they can
`facilitate cancer as Well as treat it. It is Well knoWn that in
`order for tumors to groW and spread, they must have an
`adequate blood supply, so angiogenesis is a necessary part of
`a cancer’s progression (Folkman, J. Natl. Cancer Inst.,
`82:4—6, 1990). Further, the continuous stimulation of
`neovasculariZation is also a prerequisite for metastasis
`(Weidner et al., N.E.J.M., 324:1—8, 1991). Tumor angiogen
`esis may be mediated by dysregulation of certain cytokines
`Which play a role in the normal angiogenic process (Rosen,
`EXS, 65:301—10, 1993). Angiogenesis involves a series of
`discrete steps commencing With the formation of neW cap
`illaries derived from the existing microvasculature
`(Folkman, Adv Cancer Res., 43:175—203, 1985). Initially,
`protease degradation of the basement membrane of the
`parent blood vessel enables endothelial cell migration into
`the tissue in response to an angiogenic stimulus. These
`migrating endothelial cells differentiate into a lumen or
`sprout Which increases in length With time as endothelial
`cells proliferate. Since there are a series of discrete steps
`involved in angiogenesis, this has presented a opportunity
`for development of a number of therapies each With a
`markedly different mechanism of action. Optimal anti
`angiogenic therapy, therefore, may involve multiple thera
`peutic interventions at the different steps of angiogenesis.
`The folloWing are examples of some of these cytokine
`based approaches to anti-angiogenic and/or cancer therapy:
`1) Agents such as lisofylline (CT1501R) and CT2584
`inhibit tumor angiogenesis by interfering With the lipid
`second messenger phosphatidic acid Which is common
`to both angiogenic groWth factors and autocrine tumor
`groWth factor production;
`2) Antibodies against the transmembrane glycosylated
`185 KD tyrosine kinase of erbB2 oncogene neu. Ampli
`?cation of erbB2 has an adverse effect in patients With
`breast cancer (Slamon et al., Science, 235:177—82,
`1987). An antibody against p185 causes transformed
`neu cells to revert to a nontransformed phenotype.
`GroWth of tumor xenografts Were inhibited by a mono
`clonal antibody to p185 in a dose dependent manner
`(Drebin et al., Proc. Natl. Acad. Sci. (USA),
`83:9129—33, 1986). An antibody to the product of
`erbB2 can inhibit proliferation of breast adenocarci
`noma cells Which express elevated levels of p185
`(Kumar et al., Mol. Cell Biol. 11:979—86, 1991);
`3) Protease inhibitors such as Batismastat (BB94), an
`anti-metalloprotease, as Well as cartilage and eye
`derived protease inhibitors. Each inhibits proteases
`involved in a number of steps of angiogenesis including
`degradation of the basement membrane of parent
`venules to facilitate endothelial cell escape during
`capillary sprouting and migration (Moses and Langer,
`Biotechnology, 9:630—34, 1991);
`4) Antibodies against the tumor vasculature itself, such as
`antibody to vitronectin (integrin avB3) Which blocks
`interaction betWeen this receptor and matrix proteins
`resulting in apoptosis of dividing immature endothelial
`cells;
`5) Inhibitors to such heparin binding groWth factors as the
`?broblast groWth factors (FGF), Which are involved in
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`6,140,346
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`7
`tumor growth and/or angiogenesis. The affinity of FGF
`for heparin regulates their function in vivo. Heparin
`produced by vascular endothelial cells (Nader et al.,
`Proc. Natl. Acad. Sci. (USA), 84:3565—9, 1987) can
`break doWn into loW molecular Weight degradation
`products (Vannucchi et al, Biochem. Biophys. Res.
`Commun, 140:294—301, 1986). It is believed that such
`degradation products act as a heparin transport system
`for FGF’s into endothelial cells (Folkman and Ingber,
`In Angiogenesis: Regulatory Role of Heparin and
`Related Molecules, Lane, Lindahl Editors London:
`EdWard Arnold, 317—333, 1989). Agents such as pen
`tosan polysulfate, platelet factor 4 (PF4) and protamine
`act as inhibitors of such heparin-binding groWth
`factors, such as FGF’s by binding to heparin and thus
`preventing it from groWth factor binding (Folkman and
`Shing,Adv. Exp. Med. Biol., 313:355—64, 1992). Chick
`embryo and rabbit cornea animal models have demon
`strated that such agents inhibit angiogenesis (Taylor et
`al., Nature, 297:307—12, 1982) and tumor groWth in
`animals (Maione, Science, 247:77—9, 1990; Cancer
`Res., 51:2077—2083, 1991);
`6) Angiostatic steroids are combinations of heparin
`derivatives and glucocorticosteroids Which inhibit cap
`illary endothelial cell proliferation (Sakamoto et al.,
`Cancer J., 1:55—58, 1986); and tumor extracts from
`animals treated With the tWo substances can inhibit
`endothelial cell migration (Rong et al., Cancer,
`57:586—90, 1986). One mechanism of action for these
`angiostatic steroids maybe by in?uencing endothelial
`cell migration and proliferation or by dissolving the
`basement membrane resulting in a loss in capillary
`viability (Ingber et al., Endocrinology, 119:1768—75,
`1986);
`7) Thrombospondin is a 140 KD protein that inhibits
`angiogenesis in vivo in the the corneal pocket assay and
`capillary endothelial cell migration in vitro (Good et
`al., Proc. Natl. Acad. Sci. (USA), 87:6624—8, 1990).
`Thrombospondin has a high affinity for heparin deriva
`tives (Folkman and Shing, Adv. Exp. Med. Biol.,
`313:355—64, 1992).
`8) Cytokines such as IL-12 Which exhibit preliminary
`evidence of an inhibitory effect on angiogenesis.
`In addition to the previously cited angiogenic interven
`tions used to treat cancer, applicants have developed a novel
`approach to antiangiogenic therapy Which is based on the
`role of IL-1 beta, TNF alpha and basic FGF (bFGF) play in
`tumor development and angiogenesis.
`IL-1 beta and TNF-alpha can stimulate tumor cell mobil
`ity and invasiveness by eliciting the expression of plasmi
`nogen activators in tumor cells. Such plasminogen activators
`convert latent proenZyme plasminogen into plasmin, a serine
`protease that degrades the basement membrane of the
`microvasculature and facilitates tumor cell spread from the
`blood into adjacent tissues (Rosen et al., EXS, 65:301—10,
`1993). Further TNF-alpha also stimulates endothelial cell
`motility in vitro (Leibovich, Nature, 329:630—632, 1987;
`Rosen et al., from Cell Motility Factors, Goldberg and
`Rosen, Editors Verlag, Basel, pg. 194—205, 1991) and dem
`onstrates strong angiogenic activity in vivo (Leibovich et al.,
`Nature, 329:630—632, 1987; Frater-Schroder et al., Proc.
`Natl. Acad. Sci. (USA), 84:5277—5281, 1987). IL-1 beta and
`TNF-alpha are important factors in in vitro induction of the
`endothelial cell-leukocyte receptor E-selectin (Bevilacqua et
`al., Science, 243:1160—65, 1989), VCAM1 (Elices et al.,
`Cell 60:577—84, 1990) and ICAM (Rothein et al., J.
`Immunol, 137:1270—4, 1986); and of dermal vasculature in
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`vivo. It is believed that expression of macrophage receptors
`on the surface of endothelial cells facilitates the binding of
`these cells that is the precondition to transendothelial migra
`tion. Once in the tissues, macrophages are believed to act as
`an angiogenic stimulus by secreting angiogenic substances
`such as bFGF (Frater Schroder et al., Proc. Natl. Acad. Sci.
`(USA), 84:5277—5281, 1987). Gross et al. (J. Natl. Cancer
`Inst., 85:121—131, 1993) shoWed that bFGF stimulates pro
`liferation in some tumor cells and facilitates tumor vascu
`lariZation.
`Thalidomide has been shoWn to inhibit TNF-alpha pro
`duction in erythema nodosum leprosum patients (Sarno et
`al., 1991) and in vitro stimulated monocytes (Sampaio et al.,
`J. Exp. Med., 173:699—703, 1991). Shannon et al. (Amer
`Soc. for Microbiology Ann. Meeting, Abst. U-53, 1990)
`indicated thalidomide inhibited IL-1 beta production in
`vitro. Furthermore, D’Amato et al. (Proc. Natl. Acad. Sci.
`(USA), 91:4082—5, 1994) demonstrated that thalidomide
`Was an effective inhibitor of angiogenesis induced by bFGF
`in the rabbit cornea micropocket assay. In light of thalido
`mide inhibitory activity on IL-1 beta, TNF-alpha and bFGF
`and the role these cytokines to play in angiogenesis, the
`purpose of this invention is to use thalidomide alone or in
`combination With other anti-cancer and/or anti-angiogenic
`therapies to treat cancer. An example of such combination
`therapy could involve thalidomide given With pentoxifylline
`and a glucocorticoid such as dexamethasone. The activity of
`each of these agents Would be expected to enhance that of
`the other tWo in inhibiting TNF-alpha synthesis since each
`of these agents acts as a inhibitor at a different point in this
`synthesis. Pentoxifylline inhibits TNF-alpha gene transcrip
`tion (Doherty et al., Surgery, 1101192, 1991), While thali
`domide enhances TNF-alpha m-RNA degradation (Moreira
`et al.,J. Exp. Med., 177:1675—80, 1993) and glucocorticoids
`such as dexamethasone inhibit TNF-alpha m-RNA transla
`tion (Han et al. J. Exp. Med., 172:391, 1990).
`Thalidomide Was ?rst synthesiZed and marketed in the
`1950’s as a sedative. The toxicity of the compound Was so
`loW that a dose killing 50% of animals (LDSO) could not be
`established. Thalidomide Was therefore thought to be a safer
`alternative to barbiturates. In 1961 thalidomide administered
`to pregnant Women resulted in an epidemic of congenial
`malformations. The incidence of malformed babies paral
`leled the sales of thalidomide and quickly dropped off When
`thalidomide Was removed from the market.
`Oral administration of thalidomide in the range of
`100—200 mg in adult humans results in a peak blood level of
`0.9—1.5 mg/liter after 4—6 hours. Hydrolytic cleavage of
`thalidomide occurs in vitro, the rate of Which increases as
`the pH increases. HoWever, hydrolytic cleavage of thalido
`mide in serum is much sloWer than in vitro at pH 7.4. This
`may be due to thalidomide being highly bound to plasma
`proteins. Studies in animals demonstrated high thalidomide
`concentrations in the gastrointestinal tract, liver and kidneys
`With loWer concentrations in muscle, brain and adipose
`tissue. In pregnant animals, thalidomide can pass across the
`placenta. Although a complete study of thalidomide metabo
`lism in humans has not been performed, in animals the main
`pathWay for thalidomide breakdoWn appears to be nonen
`Zymatic hydrolytic cleavage.
`Even though immunodulatory effects of thalidomide have
`not been clearly de?ned at the molecular level, thalidomide
`has been used to treat a number of immunologically based
`diseases such as: aphthous ulcers (Jenkins et at., Lancet,
`2:1424—6, 1984; Grinspan, J. Amer Acad. Dermatol,
`12:85—90, 1985; RevuZ et al., Arch. Dermatol, 126:923—7,
`1990), Graft vs Host Disease (Lim et al., Lancet, 1:117,
`
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`6,140,346
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`9
`1988; McCarthy et al., Lancet, 2:1135, 1988; Henley et al.,
`Lancet, 2:1317, 1988), erythema nodosum leprosum
`(Sheskin, Lepr. Reu, 36:183—7, 1965; Sheskin and Convit,
`Int. J. Lepn, 37:135—46, 1969; Pearson and Vedagiri, Lepr.
`Reu, 40:111—6, 1969), Behcet’s syndrome (Saylan and
`Saltik,Arch. Dermatol 118: 536, 1982; JoriZZo et al.,Arch.
`Int. Med, 146:878—81, 1986), actinic prurigo (Londono, Int.
`J. Dermatol, 12:326—8, 1973; Lovell et al., Brit. J.
`Dermatol, 108:467—71, 1983), ulcerative colitis (Waters et
`al., Brit. Med. J., 1:792, 1979) and discoid lupus erythema
`tosus (Knop et al.,Arch. Dermatol Res., 271:165—70, 1981).
`In these studies, dosages of thalidomide ranging from 100
`mg/day to 800 mg/day Were administered Without serious
`side effects.
`
`SUMMARY OF THE INVENTION
`The primary objective of the present invention is to
`provide a method for the treatment of angiogenesis accom
`panying cancer With antiangiogenic agents, including inhibi
`tors of cytokines and groWth factors.
`A further objective of the present invention is the treat
`ment of cancers With thalidomide alone or in combination
`With other agents that inhibit angiogenesis, including cytok
`ines and groWth factors, and/or With other classes of anti
`cancer therapeutics.
`Another objective of the current invention is to provide a
`method for treating cancer With thalidomide at a given
`regimen.
`An additional objective of the current invention is to
`provide compositions of matter comprising one or more
`antiangiogenic agents and/or cytokine and/or groWth factor
`inhibitors With one or more anticancer therapeutics.
`A further objective of the present invention is a method
`for the treatment of cancers Which comprises therapy With
`thalidomide and other drugs on alternative days by diverse
`schedules.
`An additional objective of the current invention is to
`utiliZe thalidomide alone or in combination With oth