This document discusses tyrosine kinase inhibitors and their role in cancer therapy. It begins by introducing tyrosine kinases and their importance in cellular signaling pathways. Tyrosine kinases are implicated in cancer development and progression. The document then discusses the classification, structure, and mechanisms of tyrosine kinase receptors. It provides examples of FDA-approved tyrosine kinase inhibitors for various cancers. The document discusses strategies for inhibiting EGFR signaling, including monoclonal antibodies and small molecule tyrosine kinase inhibitors. It also provides information on trastuzumab and its role and use for HER2-positive breast cancer.

1. •Tyrosine kinase inhibitors-
cml,breast ,lung ,head and
neck

2. Introduction
 Tyrosine kinases are important mediators of the signaling cascade, determining key roles in
diverse biological processes like growth, differentiation, metabolism and apoptosis in response
to external and internal stimuli.
 A tyrosine kinase is an enzyme that can transfer a phosphate
group from ATP to a protein in a cell. It functions as an “on”
or "off" switch in many cellular functions.
 Tyrosine kinases are implicated in several steps of neoplastic
development and progression.
 Tyrosine kinases represent a major portion of all oncoprotein
that play a transforming role in a plethora of cancers.
Structural Classification of Proteins (SCOP)
• Class: Alpha and beta proteins (a+b)
• Fold: SH2-like
• Superfamily: SH2 domain
• Family: SH2 domain
• Protein Domain: Tyrosine-protein kinase
2

3. Introduction cont.
 The identification and development of therapeutic agents for disease states that are
linked to abnormal activation of tyrosine kinases due to enhanced expression,
mutation or autocrine stimulation leading to abnormal downstream oncogenic
signaling have taken a center stage as a potent target for cancer therapy.
 The discovery that SRC oncogene having a transforming non receptor tyrosine
kinase activity , and the finding of EGFR, the first receptor tyrosine kinase paved
the way to the understanding of the role and significance of tyrosine kinase in
cancer
3

4. General Characteristic
 The human genome contains about 500 protein kinase genes and they constitute about 2% of all human genes.Up to
30% of all human proteins may be modified by kinase activity.
 Protein Tyrosine Kinase generally made up of Transmembrane Glycoprotein.
 Substrate Specificity.
4

5. Structure
5

6. Biochemical mechanismof action of tyrosine kinase
Schematic representation of the mode of action of tyrosine kinase. PK represents protein kinase and PP
stands for protein phosphatase
6
 …

7. Mechanismof Tyrosine Kinase Receptors
 When the receptors aggregate, the tyrosine kinase domains phosphorylate the C terminal tyrosine
residues.
 This phosphorylation produces binding sites for proteins with SH2 domains. GRB2 is one of these
proteins. GRB2, with
SOS bound to it, then binds to the receptor
complex. This causes the activation of SOS.
7

8. Mechanismof Tyrosine Kinase Receptors
 SOS is a guanyl nucleotide-release protein (GNRP). When this is activated, it causes certain G proteins
to release GDP and exchange it for GTP. Ras is one of these proteins. When ras has GTP bound to it, it
becomes active.
 Activated ras then causes the activation of a cellular kinase called raf-1.
8

9. Mechanismof Tyrosine Kinase Receptors
 Raf-1 kinase then phosphorylates another cellular kinase called MEK. This cause the activation of
MEK.
 Activated MEK then phosphorylates another protein kinase called MAPK causing its activation.
This series of phosphylating
activations is called a kinase cascade.
It results in amplification of the signal.
9

10. Mechanismof Tyrosine Kinase Receptors
 Among the final targets of the kinase cascade are transcriptions factors (fos and jun
showed here). Phosphorylation of these proteins causes them to become active and
bind to the DNA, causing changes in gene transcription.
10

11. Classificationof RTK
11
 Receptor tyrosine kinases (RTKs)-The RTK family includes the receptors for insulin
and for many growth factors such as
 Epidermal growth factor (EGF)
 Fibroblast growth factor(FGF)
 Platelet-derived growth factor (PDGF)
 Vascular endothelial growth factor(VEGF)
 Nerve growth factor (NGF)
 Nonreceptor tyrosine kinases (NRTKs)
 Src
 Janus kinases (Jaks)
 Abl

12. Application
 Tyrosine kinases as targets for anticancer agents
12

13. Application
13

14. • Targeted therapy is a type of medication
which blocks the growth of cancer cells by
interfering with specific targeted molecules
needed for carcinogenesis and tumor growth,
survival, angiogenesis,invasion and metastasis
rather than by simply interfering with rapidly
dividing cells.

15. Targeted Therapy in Oncology
 Goals
 Identify potential targets
– Identify agents that target tumor-specific
molecules, thus sparing normal cells
• Increased specificity leads to decreased toxicity
– Identify ideal drug target
• Drives tumor growth
• Turns on key mechanisms of cancer progression
• Reversible by inhibition with agent
• Dispensable in normal cells
• Target measurable in tumor tissue

16. Six Essential Alterations
in Cell Physiology in Malignancy
Limitless replicative
potential
Tissue invasion
& metastasis
Sustained
angiogenesis
Insensitivity to
anti-growth signals
Self-sufficiency in
growth signals
Evading
apoptosis
Targets for classical drugs?
Targets for novel drugs?
Hanahan & Weinberg,
Cell 100:57 (2000)

17. Evolution of targeted therapy-Recommendation
• Rituximab- Chimeric monoclonal antibody against CD20-
1. Refractory /low grade follicular lymphoma
2. Mainstay with CHOP/CVP in DLBCL ,Follicular lypmhoma
• Imatinib (Gleevac)- bcr/abl TKI
1. Interferon refractory CML
2. Approved For CML (Blast ,Accelerated), Unresectable/metastatic GIST, Ph + ALL
• Dasatinib
1. phases of CML with resistance or intolerance to prior therapy, including imatinib.
2. Ph-positive ALL with resistance or intolerance to prior therapy
• Nilotinib
1. Chronic phase or accelerated phase Ph- positive CML for adult patients resistent to
or intolerant of prior imatinib therapy
• Gefitinib
1. locally advanced or metastatic NSCLC who have failed platinum-based and
docetaxel chemotherapies
FDA-May 2001
FDA Oct 2007
July 2002
FDA-1997

18. • Erlotinib
1. locally advanced or metastatic NSCLC after failure of at least one prior
chemotherapy regimen
2. combination with gemcitabine for the first-line treatment of patients
with locally advanced, unresectable or metastatic pancreatic cancer.
• Lapatinib
1. combination with capecitabine for the treatment of patients with
advanced or metastatic breast cancer whose tumors overexpress HER2
and who have received prior therapy including an anthracycline, a taxane,
and trastuzumab
• Sunitinib
1. GIST after disease progression on or intolerance to imatinib mesylate
2. Advanced renal cell carcinoma
• Sorafenib
1. Advanced renal cell carcinoma
FDA Nov 2004
FDA March 2007
FDA Dec 2005
FDA Feb 2007

20. Target ??
• Major biological pathways
– Cell proliferation
– Cell cycle check
– Angiogenesis
– Apoptosis
– Senesence
– DNA repair

21. Theoretical advantage over chemotherapy
• Chemotherapy  the main drawback lies in its
exacerbation of acute and late RT-induced toxicity to
normal tissues.
• Targeted agents
•  Theoretical advantage over chemotherapy
•  Relative tumor-specificity
•  Wide therapeutic margin
•  Overlapping toxicity with RT on normal tissue is potentially minimized.
•  Improve therapeutic index
• 400 – 500 drugs under development
• Challenge  target specificity and acceptable toxicity

22. Introduction of molecular-targeted agents:
an important paradigm-shift in our approach
to the treatment of cancer
4. Proteasome
1
2
3
4
5
6
1. Growth factors and
growth-factor receptors
HER family, VEGF/R, c-kit/SCFR
2. Signal-transduction pathways
Ras, raf, MAPK, MEK, ERK,
protein kinase C, PI3K
3. Tumor-associated
antigens/markers
Gangliosides, CEA, MAGE,
CD20, CD226. Extracellular matrix/
angiogenic pathways
MMPs, VEGF, integrins
5. Cell-survival pathways
Cyclin-dependent kinases,
mTOR, cGMP, COX-2, p53, Bcl-2
Ullrich A. Oncology 2002;63(Suppl. 1):1–5
Tumour
cell

23. HER (erbB) & VEGF Family)
• HER & erbB Family
– EGFR Inhibitors
• Monoclonal Antibodies- Cetuximab, Panitumumab
• Tyrosine Kinase Inhibitors- Gefitinib, Erlotinib
– HER 2 Inhibitors
• Monoclonal Antibodies- Trastuzumab, Pertuzumab
• Tyrosine Kinase Inhibitors
• VEGF Family
– VEGF Inhibitors
• Monoclonal Antibodies- Bevacizumab
• Tyrosine Kinase Inhibitors

24. Multi Targeted Therapies
• Dual kinase Inhibitor
– EGFR/VEGF Inhibitors
• Tyrosine Kinase Inhibitors- Vandatanib (ZD6474)
– EGFR/HER 2 Inhibitors
• Tyrosine Kinase Inhibitors- Lapatinib
• Multi kinase Inhibitor
– VEGFR, PDGFR, KIT and FLT3R
• Tyrosine Kinase inhibitor- Sunitinib
– VEGFR2 and VEGFR3, FLT-3, PDGFR, c-KIT
• Tyrosine Kinase Inhibitor- Sorafenib
– Sorafenib is an oral inhibitor of RAF

25. Targeted Therapies
• Kinase Inhibitors
–PDGFR Inhibitors-
• Tyrosine Kinase Inhibitors- Imatinib
–Proteosome Inhibitors – Apoptosis
• Tyrosine Kinase Inhibitors- Bortezomib

26. Molecular targeted therapy
• Large molecules
(antibodies)
– long t1/2 less frequent adm
– High specificity
– Too large to cross epi.
less GI toxicity
– Limited bioavailability
/Distibution to certain
anatomic sites
– Risk of allergic/
anaphylactic response
• Small molecules
– Short t1/2 daily dosing
– Oral bioavailability
– No antibody response
– High tissue penetration
– High GI toxicity

27. TK Intracellular
Domain
Transmembrane
Domain
Extracellular
Domain
EGFR Structure

28. Overexpression of ErbB-1 and
ErbB-2 in Solid Tumors
Tumor Type
Overexpressing ErbB-1
(%)
Overexpressing ErbB-2
(%)
Bladder 31%-48% 7%-36%
Breast 14%-91% 10%-37%
Colorectal 25%-77% 7%
Esophageal 71% 13%-73%
Glioma 40%-50% –
NSCLC 40%-80% 3%-56%
Ovary 30%-75% 20%-32%
Pancreatic 30%-50% –
Renal 50%-90% 24%-40%
Head and Neck 30%-75% 32%-62%
Stomach – 5%-55%
Rowinsky. Horiz Cancer Ther 2001; 2:3-35; Itakura et al. Cancer 1994; 74:795-804

29. TK TKTK
erbB1
HER1
EGFR
erbB2
HER2
neu
erbB3
HER3
erbB4
HER4
No specific
ligands -
often acts as
dimer partner Heregulins
NRG2
NRG3
Heregulins
β-cellulin
EGF, TGFa , b Cellulin
Amphiregulin, HB-EGF
Human Epidermal Growth Factor Receptor Family

30. TK
EGFR Function in Normal Cell
TKATP ATP
Cell Proliferation Antiapoptosis
Angiogenesis
Gene Transcription
Cell Cycle Progression
+

31. TKTK
EGFR signal transduction in tumour cells
Survival
(anti-apoptosis)
PI3-K
STAT3
AKTPTEN
MEK
Gene transcription
MAPK
Proliferation/
maturation
Chemotherapy /
radiotherapy
resistance
Angiogenesis
Metastasis
pY
pY
RAS RAF
SOS
GRB2pY
G1
SM
G2

32. TK TK TK TK
Strategies to inhibit EGFR signaling
-
- - -
EGFR tyrosine
kinase inhibitors
Anti-EGFR mAbs
Anti-ligand
mAbs
Bispecific
Abs
Immuneeffectorcell
ATP

33. EGFR signal transduction in tumor
cells
Survival
(anti-apoptosis)
PI3-K
EGFR
Ligand
PTEN AKT
STAT3
MEK
Gene transcription
Cell cycle progression
DNA Myc
Myc Cyclin D1
JunFos
P P
MAPK
Proliferation /
maturation
Chemotherapy /
radiotherapy
resistance
Angiogenesis
Metastasis
Cyclin
D1
EGFR-TKKK
pY
pY
RAS RAFSOS
GRB2pY

34. FDA-Approved TKIs
Generic Name Cancer
Imatinib CML,GIST, others
Dasatinib CML,ALL
Nilotinib CML
Gefitinib Lung
Erlotinib Lung, Pancreas
Lapatinib Breast
Sorafenib Kidney, Liver
Sunitinib Kidney

36.  In recent years,TKs have increasingly become an important focus in
targeted drug development.2,3,4,5,6There are two main groups ofTKs:
receptorTKs and nonreceptor (cellular)TKs. ReceptorTKs, which consist
of an extracellular domain, a transmembrane domain, and an
intracellular domain, are stimulated by growth factors, and recruit a
series of downstream effector molecules to conduct complex activation
pathways. NonreceptorTKs are present within the cytoplasm, nucleus, or
the intracellular portion of the plasma membrane. SeveralTKs have been
implicated in oncogenesis, and research in cell signaling has allowed
insight into how aberrant activation of signaling cascades originating
fromTKs contributes to the formation of tumors.Thus, antitumor
properties resulting fromTK inhibition is an important focus for drug
development.Two methods of inhibitingTK activation have been used
 First, monoclonal antibodies have been used to compete for the
extracellular ligand domain of receptorTKs through ligand sequestration
(e.g., bevacizumab) or receptor binding (e.g. cetuximab).These
antibodies limit binding of the actual ligand and prohibit activation of
the ensuing signal cascade. Several monoclonal antibodies directed
against the extracellular domain of receptorTKs have shown promise
against a variety of tumor types; however, most kinase activities are
located in the intracellular domain.

37. The second method of blockingTK activation is
through the use of agents that prohibit the
phosphorylation of intracellular tyrosine residues
located on receptorTKs (e.g., erlotinib) or cytosolic
TKs (e.g., imatinib) through the blocking of their
adenosine 5′-triphosphate (ATP)-binding sites
These agents are referred to as small-molecule
tyrosine kinase inhibitors (TKIs).

38. Role of EGF INHIBITORS IN
BREAST CANCER
TRASTUZUMAB

39. Transtuzumab /Herceptin ( Genetech)
• Recombinant humanised antibody directed against extracellular domain of Her2/neu EGFR.
• MOA:-Downregulates Her2/neu receptor/Inhibits signalling/Apoptosis/ADCC /CMCL
• Half life 5-6 D
• Approved Indications:
1. MBC- First line with taxane in Her-2/neu postive tumours
2. MBC –second/third line single agent
3. Adjuvant therapy Node positive/Her-2/neu positive breast cancer with standard AC+Taxane
• Doses: 8 mg/kg over 90 mins loading followed by 6 mg/Kg 3weekly over 30 min
• Doses: 4 mg/kg loading over 90 min followed by 2 mg/kg weekly over 30 min
• Caution/ toxicity
1. Baseline LVEF>55% (cautious with antracyclines)- CHF
2. Infusion reactions-fever, chills, bronchospasm,flushing,palpitaion,hypotension,angioedema
3. Pulmonary infiltrates
4. Myelosuppression.

40. Normal HER2 expression
Normal Epithelial cell has 2 copies of HER 2 gene
& 20000 to 50000 HER 2 receptors on cell surface

41. HER2 amplification  HER2
overexpression
Mutations affecting HER 2 gene results in gene amplification thereby
Causing 100 fold increase in no. of HER 2 receptors on cell surface

42. HER2 overexpression  tumour proliferation
Excess amounts of HER 2 leads to Tumor Proliferation
Prof. Tim Cooke at Special EONS symposia, ECCO 10, Austria

43. Binding of Trastuzumab to HER2

44. HER2 in Breast Cancer
Slamon et al. 1987
HER2 oncoprotein
overexpression
HER2 oncogene
amplification Shortened median survival
HER2 overexpressing 3 years
HER2 normal 6–7 years

45. Trastuzumab (Herceptin)
• Humanised monoclonal antibody against EC domain
of HER2
• 20-30% of CaBR  overexpress/amplification HER2
 poor response
• Poorly diff / high grade
• Lack ER positivity  poor res. to HT
• Low Tpot, high S-phase, MIB-1, Ki-67
• Poor res. to CT (5FU,MTx,Cyclophos)
• Single agent in MBC response  14%
• Phase I  Herceptin + CTRT in Ca
Esophagus(pacli+cisplat)  feasible

46. 0
No membrane staining is observed, or staining is observed
in <10% of tumor cells.
Receptors/Cell ~20,000
1+
A faint/barely perceptible membrane staining is detected in
>10% of the tumor cells. The cells are stained only in part of
their membrane. Receptors/Cell ~100,000
2+
A weak-to-moderate complete membrane staining is observed in
>10% of the tumor cells. Receptors/Cell ~500,000
3+
A moderate-to-strong complete membrane staining is
observed in >10% of the tumor cells. Receptors/Cell ~1-2
million
HER-2:GRADING

47. FISH for HER2 status detection
Normal Amplification

48. 1694 pts
Menopausal: both
LN: both
Hormone: both
HER2+
Adjuvant C/T
New England Journal of Medicine 2005; 353: 1659-1672HERA
2001-2005
Adjuvant C/T
Adjuvant C/T Herceptin 1 yr
Herceptin 2 yr
Observation
Herceptin: 8mg/kg loading, 6mg/kg q3w

53. NSABP B-31
2000-2005
AC x 4
T: 225mg/m2, q3w
H: 4mg/kg ->2mk/kg/wk
A: 60mg/m2, D1
C: 600mg/m2, D1
q3w
AC x 4
2043 pts
Menopausal: both
LN: positive
Hormone: both
HER2+
T x 4
T x 4
H x 52
1
2
NCCTG N9831
2000-2005
2766 pts
Menopausal: both
LN: both
Hormone: both
HER2+
AC x 4 H x 52
AC x 4
AC x 4 T x 12 T: 80mg/m2/wk
A
B
C
New England Journal of Medicine 2005; 353: 1673-1684
T x 12
T x 12
H x 52

54. Joint Analysis
AC x 41
AC x 4A
AC x 4
T x 4
2
AC x 4C
1679 pts
1672 pts
H x 52
H x 52
New England Journal of Medicine 2005; 353: 1673-1684
DFS
OS
T x 12
T x 12
T x 4 q3w
qw

55. FinHer, Finland
2000-2003
1010 pts
Menopausal: both
Hormone: both
LN: positive or
LN- & <2cm & PR-
Vinorelbine x 3
Taxotere x 3 FEC x 3
FEC x 3
Herceptin (qw) x9
Vinorelbine x 3
Taxotere x 3
FEC x 3
FEC x 3
Herceptin (qw) x9
HER2+
232 pts
HER2-
778 pts
F:600mg/m2,D1
E:60mg/m2, D1
C:600mg/m2,D1
N: 25mg/m2, D1,8,15; q3w
T: 100mg/m2, D1; q3w
H: 4mg/kg  2mg/kg,qw q3w
Vinorelbine x 3
Taxotere x 3 FEC x 3
FEC x 3

57. The median left ventricular
ejection fraction of trastuzumab-treated patients remained unaltered during
the 5-year follow-up;
only one woman treated with trastuzumab was diagnosed with a heart failure.

61. Meta -analysis

62. OS and DFS better for Herceptin

63. LAPATINIB-dual kinase inhibitor

64. Lapatinib: Targeting EGFR
and HER2
• Lapatinib oral
tyrosine kinase
inhibitor of ErbB1
and ErbB2
– Blocks signaling through
EGFR and HER2
homodimers and
heterodimers
– May also prevent
signaling between
ErbB1/ErbB2 and other
ErbB family members
Rusnak DW, et al. Mol Cancer Ther. 2001;1:85-94.
Xia W, et al. Oncogene. 2002;21:6255-6263.
PTEN Lapatinib
P13K
pAkt
Ras
Raf
pErk
Shc
Grb2
So8
Phospholipid cell
membrane

65. Lapatinib- Tykerb (GSK)
• Small molecule dual TKI- intracellular domain of EGFR/HER-2neu
• Metabolised By CYP3A4 liver microsomal enzymes.
• Approved indication:-
1. With cepcitabine in advanced/metastatic Her-2/neu breast cancer progressed on
antracyclines, taxanes and herceptin
• Dose: 1250 mg PO D1-21 with Cepcitabine 1000mg/m2 D1-D14 in 21 day cycle.
• Drug interaction: Cautious with Enzyme inducers/suppressors and with warfarin.
Caution/ toxicity
1. Diarrhoea
2. Cardiotoxicity:LVEF
3. Prolonged QT interval- hypokalemia,hypomagnesemia,hypercalcemia
4. Hepatic- raised transaminases.
5. Rash

66. LAPATINIB
• Single-agent lapatinib for HER2-overexpressing advanced or metastatic breast
cancer that progressed on first- or second-line trastuzumab-containing regimens.
1. objective tumor response and clinical benefit rates were 7.7% and 14.1%,
respectively.
Blackwell,Annals of Oncology 20: 1026–1031, 2009
• Efficacy and Safety of Lapatinib As First-Line Therapy for ErbB2-Amplified Locally
Advanced or Metastatic Breast Cancer
• The overall response rate (complete response [CR] plus partial response [PR]) was
24%
• 31% of patients derived clinical benefit (CR, PR, or stable disease for 24 weeks
Gomez et al. Clin Oncol 26:2999-3005
• Lapatinib plus Letrozole as First-Line Therapy for HER-2 Hormone Receptor–
Positive Metastatic Breast Cancer
• objective response rate (ORR) (28% versus 15%) and clinical benefit rate (CBR) (48%
versus 29%)
» SCHWARTZBERG et al, The Oncologist 2010;15:122–129

67. Lapatinib plus capecitabine versus capecitabine alone for
HER2+ (ErbB2+) metastatic breast cancer: quality-of-life
assessment
• The longer time to disease progression with lapatinib+capecitabine
versus capecitabine alone was achieved without more time with serious
AEs.
• L+C combination therapy provided on average 6.1 weeks more quality-
adjusted survival than monotherapy for patients in this study (p =0.006).
Zhou X, Breast Cancer Res Treat. 2009 Oct;117(3):577-89.

68. BCR-ABL Tyrosine Kinase Inhibitors
• Mechanism of action :
• IMATINIB & NILOTINIB: bind to a segment of
the kinase domain that fixes the enzyme in a
closed or nonfunctional state, in which the
protein is unable to bind its
substrate/phosphate donor, ATP.
• DASATINIB: binds both the open and closed
configuration of BCR-ABL kinase.

69. Imatinib (Gleevec)
69

70. BCR-ABL Tyrosine Kinase Inhibitors
• PHARMACOKINETICS 0f Imatinib / Dasatinib
• Absorption
– Oral bioavailability ~ 98%
• Distribution – highly protein bound
• Metabolism - Primarily by CYP3A4
• Elimination
– Fecal ~ 65-80% renal ~ 10-13%
– Half life = Imatinib-18 hrs, N-desmethyl derivative- 40 hrs
Dasatinib- 3-5 hrs
Nilotinib- 17 hrs

71. IMATINIB MESYLATE
• First molecularly targeted protein kinase
inhibitor to receive FDA approval.
• It targets the BCR-ABL tyrosine kinase, which
underlies chronic myelogenous leukemia
(CML).
• BCR-ABL tyrosine kinase is present in virtually
all patients with chronic myelogenous
leukemia (CML) and some patients with acute
lymphoblastic leukemia (ALL)

72. IMATINIB MESYLATE
Dosing and Administration
• Treatment of Philadelphia chromosome(+) chronic
myelogenous leukemia
– Chronic phase, initial therapy
• 400 mg PO once daily - continue as long as the patient
continues to benefit
• May increase to 600 mg PO once daily
– Accelerated phase or blast crisis
• 600 mg PO once daily - continue as long as the patient
continues to benefit
• May increase to 800 mg/day PO

73. IMATINIB MESYLATE
• Toxicity
• Gastrointestinal
– Nausea, vomiting, abdominal pain
• Edema
– Periorbital edema or peripheral edema in the lower
extremities
• Diarrhea
• Muscle cramps
• Fatigue
• Skin rash
• Cytopenias

74. Imatinib (Gleevec®)
FDA Approved Indications
• Chronic Myeloid Leukemia
• Pediatric CML
• Acute Lymphoblastic Leukemia
• Gastrointestinal Stromal Tumors
• Myelodysplastic/Myeloproliferative Diseases
• Aggressive Systemic Mastocytosis
• Hypereosinophilic Syndrome/Chronic
Eosinophilic Leukemia
• Dermatofibrosarcoma Protuberans

75. DASATINIB
• Multi-kinase inhibitor
• BCR-ABL, SRC family, c-KIT, EPHA2,
PDGFRβ
• FDA Approved Indications
– Treatment of adults with chronic, accelerated, or
myeloid or lymphoid blast phase CML
– Treatment of adults with Philadelphia-
chromosome (+) ALL with resistance or intolerance
to prior therapy

76. NILOTINIB
• Indication: treatment of chronic phase and
accelerated phase Philadelphia chromosome
positive chronic myelogenous leukemia (CML)
in adult patients resistant to or intolerant to
prior therapy that included imatinib.

77. NILOTINIB
• Pharmacokinetics
• Absorption
– Peak plasma levels – 3 hours
– Approximately 30% of an oral dose of Nilotinib is absorbed
after administration
– Food (fatty meal) increases absorption
• Distribution
– Highly protein bound
– Plasma concentrations reach a steady state only after 8
days of daily dosing

78. NILOTINIB
Toxicities
• Thrombocytopenia and Neutropenia
• QT-prolongation – with sudden death
reported
• Liver function abnormality – elevated
bilirubin,AST/ALT and alkaline phosphatase
• Electrolyte abnormality ( hyper and hypo K,
hypo Mg, Phos, Ca, Na)

79. Mechanism of resistance to Bcr-Abl kinase
inhibitors
• POINT MUTATIONS
CONTACT POINTS BETWEEN Imatinib and the
enzyme become the sites of mutation.
• Amplification of Wild type of Kinase gene
• Philadelphia –ve clones.

80. Angiogenesis
VEGF

81. Angiogenesis is involved throughout
tumour formation, growth & metastasis
Adapted from Poon RT-P, et al. J Clin Oncol 2001;19:1207–25
Stages at which angiogenesis plays a role in tumour progression
Premalignant
stage
Malignant
tumour
Tumour
growth
Vascular
invasion
Dormant
micrometastasis
Overt
metastasis
(Avascular
tumour)
(Angiogenic
switch)
(Vascularised
tumour)
(Tumour cell
intravasation)
(Seeding in
distant organs)
(Secondary
angiogenesis)

82. Bevacizumab/Avastin-Genetech
• Recombinant humanised monoclonal antibody directed against VEGF-A.
• MOA: inhibits neoangiogenesis/improves tumor blood flow/ADCC/CMCL.
• Approved indications:
1. Metastatic/advanced colorectal cancer first line with 5FU
2. Metastatic/advanced colorectal cancer second/ third line with FOLFIRI
3. Single agent in High grade gliomas progressed on previous chemotherapy
4. Her2/neu negative metastatic breast cancer as first line with taxane.
5. Metastatic RCC with Interferons.
6. Locally advance/Metastatic Adeno ca lung nonsmokers/ pheripheral/non brain mets as first line
with platin doublet.
Doses 15mg/kg (lung) 3 wkly
10mg/kg (RCC,colorectal,Brain, breast)-2 wkly
Caution/ toxicity
1. Thromboembolism/ MI
2. Hypertension
3. Hemoptysis
4. Wound dehisence/ delayed healing
5. Bowel perforation
6. GI hemorrhage, epistaxis
7. RPLS
8. Interstitial pneumonia
9. Infusional reactions
10.Nephrotic syndromme

83. The VEGF Family and Its
Receptors
Neufeld G, et al. FASEB J. 1999;13:9-22.
VEGFR-3
(Flt-4)
VEGFR-2
(Flk-1/KDR)
VEGFR-1
(Flt-1)
Angiogenesis Lymphangiogenesis
Angiogenesis
Lymphangiogenesis
PIGF VEGF-A VEGF-B VEGF-C VEGF-D

84. Targeting VEGF:
The Bevacizumab Story
P
P
P
P
VEGF
Bevacizumab

85. VEGF
Bevacizumab
P
P
P
P
VEGF Activation BLOCKED
Targeting VEGF:
The Bevacizumab Story

86. Combination therapy significantly increased the response rates
(19.8% v 9.1%; P .001); however, this did not result in a longer PFS (4.86 v
4.17 months; hazard ratio 0.98).

87. BEVACIZUMAB
•The addition of bevacizumab to paclitaxel resulted in a statistically significant
improvement in PFS (0.48, 95% CI, 0.385 to 0.607; P.0001
•Improvement in median PFS (11.3 v 5.8 months

88. LUNG
GEFITINIB (Iressa)

89. Gefitinib/Irressa (AstraZenca)
• Small molecule TKI- intracellular domain EGFR
• Proposed resistance: Mutation intracellular domain/ KRAS mutuation/ cross talk
• Metabolism: Liver CYP3A4 microsomal enzymes.
• Approved indication:
1. Locally advance/metastatic NSCLC progression to platin /taxanes based chemotherapy
• Drug interaction; Enxymes inducer/suppressors/ warfarin
• Special mention
1. Response within first few weeks of therapy
2. Bronchoalvelor ,adenoca, females ,nonsmokers,asian increased sensitivity
• CAUTION/ TOXICITY
1. Hypertension
2. Pruritis,rash
3. Hemoptysis
4. Nausea/ vomiting

90. Phase II Studies
IDEAL 1 and 2 trial design
IRESSA
250 mg/day
IRESSA
500 mg/day
Continue IRESSA until disease
progression or unacceptable toxicity
IDEAL, IRESSA Dose Evaluation in Advanced Lung cancer
Randomisation
 IDEAL 1 (n=209)
1 or 2 prior regimens
 IDEAL 2 (n=216)
>2 prior regimens
Fukuoka et al 2003; Kris et al 2003
Primary end points
 Objective tumour response
 Symptom improvement
(IDEAL 2)
 Safety (IDEAL 1)

91. Tumour response and disease
control rates with 250 mg gefitinib
IDEAL 1 IDEAL 2
18.4
0
10
20
30
40
50
60
54.4
42.2
11.8
Objective response
Disease control
Patients
(%)
Objective response, complete plus partial response
Disease control, objective response plus stable disease
Fukuoka et al 2003;
Kris et al 2003

92. IDEAL 1 and 2: rapid and durable
symptom improvement
• Symptom improvement occurred rapidly; median time
to symptom improvement was 8 days in IDEAL 1 and 10
days in IDEAL 2
• Moreover, symptom improvement was durable, with
the median duration being >6 months in both studies

93. Phase III placebo-controlled study (ISEL) of gefitinib
(IRESSA) plus best supportive care in patients with
advanced non-small-cell lung cancer (NSCLC) who
had received 1 or 2 prior chemotherapy regimens
ISEL study
Thatcher, N; Chang, A, Parikh, P et al. Lancet 2005; 366: 1527-37.
ISEL – IRESSA Survival Evaluation in Lung Cancer

94. End points
Primary:
 Survival
Secondary:
 TTF
 ORR
 QoL, symptoms
 Safety
Exploratory:
 Tumour biomarker
analysis (eg EGFR)
ISEL trial design
• 1692 patients in 210 centres across 28 countries
• Stratified for histology, gender, intolerant / refractory, PS and smoking
history
Gefitinib
(250 mg/day)
+ BSC
Placebo
+ BSC
Randomisation
(2:1 ratio)
CT, chemotherapy; BSC, best supportive care;
TTF, time to treatment failure; ORR, objective response rate; QoL, quality of life
Patients with:
 Histologically /
cytologically confirmed
NSCLC
 Locally advanced or
metastatic disease
 1 or 2 prior CT regimens
 Intolerant to most recent
CT regimen or
progression <90 days
of last CT cycle

95. 1692 Patients in 210 Centres Across
28 Countries
Northern Europe
16%
Australia
2%
Canada
1%
Central and Eastern
Europe
36%
Southern Europe
7%
Asia
24%
Central and South
America
14%

96. 0 2 4 6 8 10 12 14
Survival in the overall population
16
Time (months)
At risk: 1692 1347 877 485 252 104 31 2
Median, months
1-year survival, %
Log-rank HR (95% CI), 0.89 (0.77, 1.02); p=0.087
Cox analysis, p=0.030
Gefitinib
5.6
27
Placebo
5.1
21
0.0
0.2
0.4
0.6
0.8
1.0Proportion
surviving
Gefitinib
Placebo
HR, hazard ratio;
CI, confidence interval
Median follow-up 7 months (range 3-15), 58% deaths

97. Median, months
1-year survival, %
Log-rank HR (95% CI), 0.84 (0.68, 1.03); p=0.089
Cox analysis, p=0.033
Gefitinib
6.3
30
Placebo
5.4
18
Survival in adenocarcinoma population
Time (months)
At risk: 812 669 446 262 145 66 18 1
Gefitinib
Placebo
0 2 4 6 8 10 12 14 16
0.0
0.2
0.4
0.6
0.8
1.0Proportion
surviving

98. Survival
HR and 95% CI
0.4 0.6 0.8 1.0 1.5
Adenocarcinoma
All patients
Female
PS 0, 1
1 prior line
Refractory
Never smoked
Non-adenocarcinoma
Ever smoked
Intolerant
2 prior lines
PS 2, 3
Male
11.9%
8.0%
14.7%
8.8%
7.6%
7.9%
18.1%
4.8%
5.3%
9.4%
8.4%
6.6%
5.1%
Gefitinib ORR
Survival: effects in subsets (1)
Favours gefitinib Favours placebo

99. Survival
Survival: effects in subsets (2)
11.1%
8.0%
12.4%
7.4%
6.9%
9.0%
6.8%
7.5%
10.1%
7.7%
6.4%
7.2%
10.2%
Prior docetaxel
All patients
Asian ethnicity
<65 years
No prior docetaxel
>65 years
Non-Asian ethnicity
Prior CT response: PD/NE
Prior CT response: CR/PR
Prior CT response: SD
Time since Dx: <6 months
Time since Dx: 6-12 months
Time since Dx: >12 months
Gefitinib ORR
Favours gefitinib Favours placebo
0.4 0.6 0.8 1.0 1.5
HR and 95% CI

100. Survival by smoking history
Gefitinib
Placebo
Proportionsurviving
0 2 4 6 8 10 12 14 16
0.0
1.0
0.8
0.6
0.4
0.2
Time (months)
0 2 4 6 8 10 12 14 16
Cox regression HR (95% CI),
0.92 (0.79, 1.06); p=0.242
Median: 5.0 vs 4.9 months
Never smoked (n=375) Ever smoked (n=1317)
Cox regression HR (95% CI),
0.67 (0.49, 0.92); p=0.012
Median: 8.9 vs 6.1 months

101. Survival by ethnic originProportionsurviving
Time (months)
Cox regression HR (95% CI),
0.92 (0.80, 1.07); p=0.294
Median 5.2 vs 5.1 months
Asian ethnicity (n=342) Non-Asian ethnicity (n=1350)
Cox regression HR (95% CI),
0.66 (0.48, 0.91); p=0.010
Median: 9.5 vs 5.5 months
0.0
1.0
0.8
0.6
0.4
0.2
0 2 4 6 8 10 12 14 16 0 2 4 6 8 10 12 14 16
Gefitinib
Placebo

102. Tolerability data
• Adverse-event (AE) profile consistent with established
safety profile for gefitinib
• Rash (37% vs 10%) and diarrhoea (27% vs 9%) were the
most common AEs for gefitinib- vs placebo-treated patients
• No difference in incidence of serious AEs (19% for gefitinib
vs 17% for placebo)
• Few withdrawals due to AEs (5% for gefitinib vs 2% for
placebo)
• No difference in the incidence of interstitial lung disease-
like events (1% in each arm)

103. • Gefitinib in combination with platinum doublets
– gemcitabine / cisplatin (INTACT 11)
– carboplatin / paclitaxel (INTACT 22)
• No survival advantage over placebo reported in
Phase III trials for Iressa (INTACT 1 and 2)
INTACT, IRESSA NSCLC Trial Assessing Combination Treatment
1st-line Iressa (Gefitinib) + CT combination
therapy in NSCLC
1Giaccone et al 2004; 2Herbst et al 2004

105. Why was there no additive effect of Gefitinib in
combination with chemotherapy in INTACT 1 & 2?
• No indication from supportive studies of a
pharmacokinetic interaction between Gefitinib and
any of the chemotherapy agents
• Possible that
– chemotherapy (at maximum tolerated dose) and Gefitinib
are targeting the same cell population and chemotherapy
response thus masks that of Gefitinib
– chemotherapy directly/indirectly affects EGFR
function/expression thereby reducing/abrogating the
effects of Gefitinib

106. •phase 3, open-label study, we randomly assigned previously untreated patients
in East Asia who had advanced pulmonary adenocarcinoma and who were nonsmoke
or former light smokers.
•gefitinib (250 mg per day) (609 patients) or carboplatin plus paclitaxel (608 patients).
•The primary end point was progression-free survival.
Ipass- Iressa Pan Asia Study

107. •rash or acne (in 66.2% of patients) and
diarrhea (46.6%) in the gefitinib group.
neurotoxic effects (69.9%), neutropenia
(67.1%), and alopecia (58.4%) in the
carboplatin–paclitaxel group.

108. First-line gefitinib for patients with
advanced NSCLC who were
selected on the basis of EGFR
mutations improved PFS, with
acceptable toxicity, as compared
with standard chemotherapy

109. Erlotinib/Tarceva ( Genetech)
• Small molecule TKI- intracellular domain EGFR
• Proposed resistance: Mutation intracellular domain/ KRAS mutuation/ cross talk
• Metabolism: Liver CYP3A4 microsomal enzymes.
• Approved indication:
1. Single agent(monotherapy) - NSCLC resistant/ progression to at least one line of chemotherapy.
2. In combination with gemcitabine as first line in advanced/ metastatic pancreatic carcinoma
• Drug interaction; Enxymes inducer/suppressors/ warfarin
• Special mention
1. Close monitor in patients with pulmonary symptoms- cough,dyspnea
2. Dose increase to 300mg/d in active smokers
• CAUTION/ TOXICITY
1. Diarrhoea
2. Interstitial pneumonia
3. Pruritis,rash
4. Hemoptysis

110. Erlotinib BR21
• randomized, placebo-controlled, double-blind trial
• stage IIIB or IV non–small-cell lung cancer, with performance status from 0 to 2
• had received one or two prior chemotherapy regimens
• 2:1 ratio to receive oral erlotinib, at a dose of 150 mg daily,or placebo.
• 731 patients, 49 percent had received two prior chemotherapy regimens

111. •response rate was 8.9 percent in
the erlotinib group and less than 1
percent in the placebo group
(P<0.001)
•median duration of the
response was 7.9 months and 3.7
months
•Overall survival was 6.7 months and
4.7 months, respectively (P<0.001)
•Progression-free survival
was 2.2 months and 1.8 months
(P<0.001)
Five percent
of patients discontinued erlotinib
because of toxic effects.

114. • TRIBUTE: A Phase III Trial of Erlotinib Hydrochloride (OSI-774)
Combined With Carboplatin and Paclitaxel Chemotherapy in
Advanced Non–Small-Cell Lung Cancer
Herbst , J Cli Onc 25;12:2007
• Erlotinib with concurrent carboplatin and paclitaxel did not confer a survival advantage over
• carboplatin and paclitaxel alone in patients with previously untreated advanced NSCLC
Phase III Study of Erlotinib in Combination With Cisplatin and Gemcitabine in
Advanced Non–Small-Cell Lung Cancer: The Tarceva Lung Cancer Investigation Trial
No improvement in survival
Non smokers

115. Phase II Trial of Cetuximab in Patients With Previously
Treated Non–Small-Cell Lung Cancer
• response rate with single-agent cetuximab in this heavily pretreated patient
population with advanced NSCLC was only 4.5%,
• the disease control rates and overall survival seem comparable to that of
pemetrexed, docetaxel, and erlotinib in similar groups of patients.
J Clin Oncol 24:5253-5258
• Randomized Phase II Trial of Docetaxel Plus Cetuximab or
Docetaxel Plus Bortezomib in Patients With Advanced Non–
Small-Cell Lung Cancer and a Performance Status of 2: CALGB
30402
• While the results in the D + C arm are numerically superior, These results confirm
the poor prognosis associated with a PS of 2 and the difficulty in translating recent
advances in targeted therapy
J Clin Oncol 27:4487-4491.

116. Targeted therapy + chemo –First line
•ECOG -878 patients with recurrent or advanced non–small-cell lung cancer (stage IIIB or
IV)
•Group A - chemotherapy with paclitaxel and carboplatin alone (444) 3 weeks for six cycles
•Group B - paclitaxel and carboplatin plus bevacizumab (434).
• bevacizumab was administered every 3 weeks until disease progression was evident
or toxic effects were intolerable
•squamous-cell tumors, brain metastases, clinically significant hemoptysis, or inadequate
organ function or performance status (ECOG performance status, >1) were excluded

117. Median Survival-12.3m Vs
10.3mP = 0.003
PFS – 6.2 Vs 4.5 mthsP<0.001
response rates of 35% and
15% (P<0.001).
bleeding were 4.4% and
0.7%, respectively
(P<0.001)
15 treatment-related
deaths in the
chemotherapy-plus-
bevacizumab group,
including 5 from pulmonary
hemorrhage..

118. Targeted therapy - Head neck

119. Cetuximab/ Erbitux (BMS/Eli Lilly)
• Recombinant chimeric IgG1 monoclonal AB- EGFR extracellular domain.
• MOA: 10 X more affinity than ligands/ inhibits EGFR signalling/ ADCC/CMCL.
• Resistance: Decreased affinity OF receptor/decreased expression/KRAS/BRAF/cross talk
• Half life :5-6 days
• Approved indications
1. Metastatic colorectal carcinoma: first line with irinotecan/irenotecan intolerant/resistant
non KRAS mutation (approved wild type KRAS)
2. Head neck cancer: Along with radiation in locally advanced HNSCC.
Dose : 400mg/m2 IV over 120 mins (loading) : 250 mg /m2 every week (maintenance)
Special mention:
Hypersensitivity to murine porteins
Level of EGFR expression does not predict cetuximab response: no need for EGFR testing.
KRAS mutation test should be performed.
Acneform rash correlated/predictor of better response/survival
Toxcity
1. Rash
2. Interestitial pneumonia
3. Infusional reactions

120. Author No. Cancer Chemother
apy
RR (%) Median PFS Median OS
Herbst 79 SCC - POD
on CDDP-
based
CDDP-
based +
cetuximab
6 – 20 2.0 - 3.0 4.3 - 6.1
Baselga 96 SCC - POD
on platin-
based
CDDP-
based +
cetuximab
10 – 11 2.4 - 2.8 4.9 - 6.0
Trigo 103 SCC - POD
on platin-
based
cetuximab 13 2.3 5.9
Burtness 117 SCC - no
chemo for
R/M
CDDP-
based
+CDDP
cetuximab
10
26
2.7
4.2
8.0
9.2
Cetuximab for Recurrent or Metastatic Head and Neck Cancer

121. EXTREME TRIAL
The response rate for patients in arm A
with skin toxicity was 33%,
compared with 7% for patients who did
not develop skin
toxicity (P.08).

122. N Engl J Med 2008;359:1116-27
Cetuximab plus platinum–fluorouracil chemotherapy improved overall survival
when given as first-line treatment in patients with recurrent or metastatic
squamous-cell carcinoma of the head and neck.

126. overall survival was significantly improved in those who experienced an
acneiform rash of at least
grade 2 severity compared with patients with no
rash or grade 1 rash (HR 0·49, 0·34–0·72; p=0·002).

128. Kalyani N, Agarwal JP et al

129. CONCLUSION
• Kinase inhibitors are most effective
against tumors that are heavily, perhaps
solely, dependent on the targeted kinase.
• Monotherapy with TKIs is limited by the
development of resistance.
Translational research
studies are critical to
understanding the results
from clinical trials of
targeted therapeutics.