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{=0A= document.writeln('

3D"Click

');=0A= }=0A= =0A= function get_text_link(url, linktext)=0A= {=0A= document.writeln('' + = linktext + '');=0A= }=0A= =0A= function get_htmlftext_link(a, b) {=0A= document.writeln("" + = b + ", ");=0A= }=0A= =0A= ------=_NextPart_000_0000_01C9474D.9BD6CF90 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://download.interscience.wiley.com/freeflow/js/personalisation.js /*=0A= * Project : Interscience Redesign=0A= * File : personalisation.js=0A= * Creation Date : 25th March 2003=0A= * Author : Jonathan Sugar=0A= *=0A= * Various functions to deliver personalisation functionality.=0A= */=0A= =0A= // Pre-declare userName so it's available when we need to test if the = page=0A= // assembler ran OK=0A= var userName =3D null;=0A= var shcrtCookie =3D null;=0A= =0A= // Browser detect globals:=0A= var uaStr =3D navigator.userAgent.toLowerCase();=0A= var uaVer =3D parseInt(navigator.appVersion);=0A= // for detecting netscape 4=0A= var netscape =3D (uaStr.indexOf("mozilla") > -1);=0A= var netscape4 =3D (netscape && uaVer < 5);=0A= =0A= // Factory Methods=0A= =0A= // Simple wraper object to encapsulate the data for a co-branding item.=0A= function coBrandingItem(image, imageAltText, href)=0A= {=0A= //alert("Making new coBrandingItem:\nImage: " + image + = "\nimageAltText" + imageAltText + "\nhref: " + href);=0A= this.image =3D image;=0A= this.imageAltText =3D imageAltText;=0A= this.href =3D href;=0A= }=0A= =0A= /*=0A= * Insert the 'Customer co-branding' section.=0A= * -----------------------------=0A= *=0A= * Author: Jonathan Sugar, March 2003.=0A= *=0A= * 1. Insert customer co branding. Loop through 'customerCoBranding' array=0A= * inserting XHTML where needed.=0A= *=0A= * NOTE: the array contains ONLY the resource location (the location of a = gif=0A= * on the file system), the required XHTML is then added where needed. = This way=0A= * we maintain the seperation between presentation and content.=0A= */=0A= function insertCustomerCoBranding(maxBranding)=0A= {=0A= if( customerCoBranding[0].image !=3D "none")=0A= {=0A= document.writeln('

');=0A= document.writeln('

');=0A= document.writeln('

' + imageAltText + '
' + imageAltText + = '
More Providers

');=0A= document.writeln('

');=0A= document.writeln('

3D""

');=0A= }=0A= }=0A= =0A= /*=0A= * Insert the 'My Area' section.=0A= * -----------------------------=0A= *=0A= * Author: Jonathan Sugar, March 2003.=0A= * Updated: Ben Marvell, April 2006=0A= *=0A= * My profile link absolute as this file isnt only run from w3 anymore.=0A= */=0A= function insertMyArea(userdata)=0A= {=0A= // just in case the page assembler isn't running.=0A= =0A= =0A= if (userName !=3D null)=0A= {=0A= document.writeln("

" + = userName.substring(0,33) + "..., access your
" + userName + = ", access your

My Profile"); =0A= } =0A= document.writeln(getLoginOutLink());=0A= //CR 3652 getAthenStatus() as added=0A= document.writeln(getAthenStatus());=0A= document.writeln("

");=0A= } else {=0A= if(typeof(environment)!=3D'undefined' && = environment=3D=3D'PRODUCTION') {=0A= document.writeln("

Log Out");=0A= document.writeln("

"); =0A= }=0A= }=0A= if (menuloadedflag){=0A= wisMenu();=0A= }=0A= }=0A= =0A= /*=0A= * Insert the Customer Admin 'Login/Logout' link=0A= * -----------------------------=0A= *=0A= * Author: Bobby Jack, December 2004.=0A= *=0A= */=0A= function insertAdminLink(page)=0A= {=0A= val =3D getCookie("AID");=0A= =0A= if (val && val !=3D "-1")=0A= {=0A= document.writeln('

Logout');=0A= }=0A= else=0A= {=0A= document.writeln('

');=0A= }=0A= }=0A= =0A= /*=0A= * Insert the username section.=0A= * -----------------------------=0A= *=0A= * Author: Jonathan Sugar, March 2003.=0A= *=0A= * 1. Insert the username.=0A= */=0A= function insertUserName()=0A= {=0A= document.write(userName);=0A= }=0A= =0A= /*=0A= * Return the appropriate link to the login/logout cgi=0A= * ---------------------------------------------------=0A= *=0A= * Author: Jonathan Sugar, March 2003.=0A= * Updated: Ben Marvell, April 2006=0A= * Had to change the links absolute as this file isnt only run from w3 = anymore.=0A= */=0A= function getLoginOutLink()=0A= {=0A= if(userName !=3D "")=0A= {=0A= return "

";=0A= }else=0A= {=0A= return "

";=0A= }=0A= }=0A= =0A= /*=0A= * Return the appropriate link to the shopping cart content page=0A= * ---------------------------------------------------=0A= *=0A= * Author: Zhiming & Warrell June 2007=0A= */=0A= function getShCrtLink(logged)=0A= {=0A= if(logged =3D=3D true )=0A= return "

";=0A= else=0A= return "

";=0A= }=0A= =0A= function toggleShCrtLink()=0A= {=0A= shcrtCookie =3D readCookie("SHCRT");=0A= if(shcrtCookie !=3D null)=0A= {=0A= if(document.all)=0A= {=0A= return true;=0A= }=0A= else=0A= {=0A= document.getElementById("shcrt_id").style.display =3D "block";=0A= }=0A= }=0A= else=0A= {=0A= if(document.all)=0A= {=0A= return true;=0A= }=0A= else=0A= {=0A= document.getElementById("shcrt_id").style.display =3D "none";=0A= }=0A= }=0A= }=0A= =0A= =0A= =0A= function readCookie(name)=0A= {=0A= var nameEQ =3D name + "=3D";=0A= var ca =3D document.cookie.split(';');=0A= for(var i=3D0; iYou are logged in = to Athens';=0A= }=0A= else=0A= {=0A= return "

";=0A= }=0A= =0A= } ------=_NextPart_000_0000_01C9474D.9BD6CF90 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://download.interscience.wiley.com/freeflow/js/site.js /************************************************************************= ***************************=0A= FILE: site.js=0A= AUTHOR: Jonathan Sugar, Chris Neatby-Smith and Digital Pulp. July = 2003.=0A= =0A= DESCRIPTION: Javascript relating to site wide functionality across =0A= InterScience.=0A= =0A= INCLUDES FUNCTIONS=0A= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=0A= =0A= Search Functions=0A= ----------------=0A= =0A= selectAndSubmit() - for deciding where to submit a query based on the = state of the form.=0A= processallContentSearch() - for validating form input for an all = content search.=0A= processTitleSearch() - for validating form input for a Title search.=0A= checkCitationSearch() - for validating the citation search form.=0A= selectAll() - check all the checkboxes in a form.=0A= do_popup() - stasa Acronym Finder window popup function.=0A= =0A= =0A= Other Functions=0A= ---------------=0A= =0A= fixInlineLists() - fix netscape 4.x bug where

tags with images = display both an image and=0A= the default bullet. =0A= =0A= = *************************************************************************= **************************/=0A= =0A= var http =3D false;=0A= if(navigator.appName =3D=3D "Microsoft Internet Explorer") {=0A= http =3D new ActiveXObject("Microsoft.XMLHTTP");=0A= } else {=0A= http =3D new XMLHttpRequest();=0A= } =0A= =0A= // Global Variables=0A= var debug =3D false;=0A= var first =3D true;=0A= =0A= // Browser detect globals:=0A= var uaStr =3D navigator.userAgent.toLowerCase();=0A= var uaVer =3D parseInt(navigator.appVersion);=0A= // for detecting netscape 4=0A= var netscape =3D (uaStr.indexOf("mozilla") > -1);=0A= var netscape4 =3D (netscape && uaVer < 5);=0A= =0A= /*=0A= * Used to switch search mode between APS and TitleFinder on quicksearch = boxes=0A= * = -------------------------------------------------------------------------= --=0A= *=0A= * 1. Decides which search is required based on the value of the radio = buttons=0A= * in 'document.formSelector.whichForm'.=0A= *=0A= * 2. Calls individual functions to process the forms and submit them.=0A= *=0A= */=0A= function selectAndSubmit()=0A= {=0A= var formSelection;=0A= =0A= // find out which form we need to process.=0A= var selector =3D document.formSelector.whichForm;=0A= for (var i =3D 0; i < selector.length; i++){=0A= if (selector[i].checked){=0A= formSelection =3D selector[i].value;=0A= }=0A= }=0A= =0A= // Call the relevent function to process the required form.=0A= if(formSelection =3D=3D "allContentSearch"){=0A= processallContentSearch(document.allContentSearchForm, = document.formSelector)=0A= }=0A= else if(formSelection =3D=3D "searchTitles"){=0A= processTitleSearch(document.searchTitles, document.formSelector)=0A= }=0A= else{=0A= return false;=0A= }=0A= =0A= //@@@DM It was anoying me this error =0A= return false;=0A= }=0A= =0A= /*=0A= *Process the ADS search form=0A= *=0A= */=0A= function trim(str)=0A= {=0A= return str.replace(/(^\s*)|(\s*$)/g,"");=0A= }=0A= =0A= function ADSquery(t) {=0A= var keyword =3D trim(t.getElementsByTagName("input")[0].value);=0A= if (keyword!=3D"") {=0A= = window.open("","popup","toolbar=3Dyes,location=3Dyes,status=3Dyes,menubar= =3Dno,scrollbars=3Dyes,resizable=3Dyes,width=3D800,height=3D500");=0A= t.target=3D"popup";=0A= t.qsearch.value=3Dkeyword;=0A= return true;=0A= = //processADSSearch(document.ADSSearchForm,document.ADSQueryForm,keyword);=0A= } else {=0A= alert("Please input a keyword for ADS searching before clicking go");=0A= return false;=0A= }=0A= }=0A= /*=0A= function processADSSearch(hiddenForm ,queryForm , str) {=0A= var terms =3D str;=0A= var formToSubmit =3D hiddenForm;=0A= var formToProcess =3D queryForm;=0A= formToSubmit.qsearch.value =3D terms;=0A= = window.open("","popup","toolbar=3Dyes,location=3Dyes,status=3Dyes,menubar= =3Dno,scrollbars=3Dyes,resizable=3Dyes,width=3D800,height=3D500");=0A= formToSubmit.action =3D = "http://adsabs.harvard.edu/cgi-bin/nph-basic_connect"=0A= formToSubmit.target =3D "popup";=0A= formToSubmit.submit();=0A= }=0A= */=0A= =0A= /*=0A= * Process the allContentSearch form=0A= * ---------------------------------=0A= * 1. Perform form validation, checking for empty fields.=0A= * Give the user a relevent message if required.=0A= *=0A= * 2. Process/Assign the appropriate form elements and submit the form.=0A= */=0A= function processallContentSearch(hiddenForm, queryForm)=0A= {=0A= var formToSubmit =3D hiddenForm;=0A= var formToProcess =3D queryForm;=0A= =0A= // Do some basic form validation=0A= if(formToProcess.terms.value !=3D "")=0A= {=0A= formToSubmit.WISsearch1.value =3D formToProcess.terms.value;=0A= formToSubmit.submit(); =0A= }=0A= else=0A= {=0A= alert("You must enter a search term in the text box before you click = go.");=0A= }=0A= }=0A= =0A= /*=0A= * Process the Title Search form=0A= * -----------------------------=0A= * 1. Perform form validation, checking for empty fields.=0A= * Give the user a relevent message if required.=0A= *=0A= * 2. Process/Assign the appropriate form elements and submit the form.=0A= */=0A= =0A= function processTitleSearch(hiddenForm, queryForm)=0A= {=0A= var formToSubmit =3D hiddenForm;=0A= var formToProcess =3D queryForm;=0A= =0A= // Do some basic form validation=0A= if(formToProcess.terms.value !=3D "")=0A= {=0A= formToSubmit.query.value =3D formToProcess.terms.value;=0A= formToSubmit.submit();=0A= }=0A= else=0A= {=0A= alert("You must enter a search term in the text box before you click = go.");=0A= }=0A= }=0A= =0A= function doCitationSearch()=0A= {=0A= var form =3D document.citsearchform;=0A= if(checkCitationSearch())=0A= {=0A= form.action =3D "/search/allsearch";=0A= form.submit();=0A= }=0A= }=0A= =0A= // Preprocesses the arguments sent to CitationSearch and checks validity = of user inputs.=0A= function checkCitationSearch()=0A= {=0A= var supplementFound =3D 0; //increment if found;=0A= var hyphenFound =3D 0; //increment if found;=0A= var fm =3D document.citsearchform;=0A= var errmsg =3D "Please use the valid digits '0' to '9'";=0A= // remove all spaces=0A= fm.volume.value =3D fm.volume.value.replace(/ /g, "");=0A= fm.issue.value =3D fm.issue.value.replace(/ /g, "");=0A= fm.pages.value =3D fm.pages.value.replace(/ /g, "");=0A= =0A= if (fm.issn.value.length > 0 && fm.volume.value.length > 0 && = fm.pages.value.length > 0)=0A= {=0A= // check page range=0A= var pageRange =3D fm.pages.value;=0A= var volume =3D fm.volume.value;=0A= var issue =3D fm.issue.value;=0A= var continueFlag =3D 0;=0A= //check the volume=0A= // if (isNaN(volume))=0A= // {=0A= // // volume failed checking=0A= // alert("Volume is invalid. "+errmsg+".");=0A= // return false;=0A= // }=0A= //check the issue=0A= if ((issue.length !=3D 0) && isNaN(issue))=0A= {=0A= // issue failed checking=0A= alert("Issue is invalid. "+errmsg+" or leave blank.");=0A= return false;=0A= }=0A= //check the page range=0A= if (isNaN(pageRange))=0A= {=0A= var isValid =3D false;=0A= // check for hyphen=0A= var hyphenIndex =3D pageRange.indexOf("-");=0A= if ((hyphenIndex !=3D -1) && (hyphenIndex =3D=3D = pageRange.lastIndexOf("-")))=0A= {=0A= // we have only one hyphen, so extract each number=0A= var firstNum =3D pageRange.substring(0, hyphenIndex);=0A= var secondNum =3D pageRange.substring(hyphenIndex + 1);=0A= // check for S=0A= var firstS =3D firstNum.indexOf("S");=0A= var secondS =3D secondNum.indexOf("S");=0A= if (firstS =3D=3D secondS)=0A= {=0A= if ((firstS =3D=3D -1) && isNum(firstNum) && isNum(secondNum) && = (firstNum.length > 0) && (secondNum.length > 0))=0A= isValid =3D true; // both inputs are digits=0A= else if (firstS =3D=3D 0)=0A= {=0A= var firstNumNoS =3D firstNum.substring(1);=0A= var secondNumNoS =3D secondNum.substring(1);=0A= if (isNum(firstNumNoS) && isNum(secondNumNoS) && = (firstNumNoS.length > 0) && (secondNumNoS.length > 0))=0A= isValid =3D true; // both inputs are Sdigits=0A= }=0A= =0A= }=0A= }=0A= if (isValid)=0A= {=0A= return true;=0A= }=0A= else=0A= {=0A= alert("The page range is invalid. "+errmsg+" and a hyphen '-' if = required.");=0A= return false;=0A= }=0A= }=0A= return true;=0A= }=0A= else=0A= {=0A= alert("Volume and pages are required fields. Please make sure data has = been entered for both fields.");=0A= return false;=0A= }=0A= }=0A= =0A= // returns true if a is an Integer.=0A= function isNum(a)=0A= { return !(isNaN(a)); }=0A= =0A= function fixInlineLists() {=0A= if (!document.getElementById) return;=0A= var allLIs =3D document.getElementsByTagName('li');=0A= var bulletNode =3D document.createElement('img');=0A= bulletNode.src = =3D"http://download.interscience.wiley.com/images/icon.bullet.gif";=0A= =0A= for (var i=3D0; iAbstract | References';=0A= }=0A= //alert("URL: " + loc + "\nStart Index: " + startIndex + "\nEnd Index: = " + endIndex + "\nPage: " + page + "\nLink Text: " + links);=0A= return links;=0A= }=0A= =0A= =0A= function selectAll(fm)=0A= {=0A= //var fm =3D document.viewSelectedForm;=0A= =0A= for (var i =3D 0; i < fm.elements.length; i++)=0A= {=0A= if (fm.elements[i].type =3D=3D 'checkbox' /*&& fm.elements[i].name = =3D=3D 'ID'*/)=0A= {=0A= fm.elements[i].checked =3D true;=0A= }=0A= }=0A= }=0A= =0A= =0A= function do_popup(file)=0A= {=0A= var w =3D window.open(file, 'popWin', = 'width=3D350,height=3D500,scrollbars=3Dyes');=0A= =0A= }=0A= =0A= =0A= function mailTool(itemID, useurl, skin)=0A= {=0A= //var url =3D "/cgi-bin/mailform?item=3D"+itemID;=0A= var url =3D "/cgi-bin/mailform?item=3D" + itemID + "&skin=3D" + skin;=0A= var parameters =3D = 'status=3Dno,scrollbars=3Dno,resizable=3Dyes,width=3D400,height=3D475';=0A= =0A= if (useurl !=3D "")=0A= {=0A= url +=3D "&useurl=3D"+useurl;=0A= }=0A= =0A= if ((isNaN(parseInt(itemID))=3D=3Dtrue)||(arguments.length >=3D 4 && = arguments[3] =3D=3D 'cluster'))=0A= {=0A= url +=3D '&type=3Dcluster';=0A= }=0A= =0A= eval("wileyMailTool =3D = window.open('"+url+"','MailTool','"+parameters+"')");=0A= =0A= // If object exists ensure has focus=0A= if (eval("wileyMailTool") && window.focus)=0A= eval("wileyMailTool").focus();=0A= }=0A= =0A= =0A= /*=0A= * 1. Find the links we need to alter.=0A= * 2. For each link apply the new styles we need.=0A= */=0A= function fixAbsRefRendering()=0A= { =0A= var table =3D document.getElementById('prerendered');=0A= var anchors =3D table.getElementsByTagName('a');=0A= for (var i =3D 1; i < anchors.length; i++)=0A= {=0A= if(anchors[i].href !=3D"") =0A= { =0A= applyAbsRefStyleCorrection(anchors[i]);=0A= =0A= }=0A= }=0A= }=0A= =0A= function applyAbsRefStyleCorrection(currentLink)=0A= {=0A= currentLink.style["color"] =3D "#369";=0A= currentLink.style["fontWeight"] =3D "normal";=0A= currentLink.style["marginLeft"] =3D "3px";=0A= currentLink.style["marginRight"] =3D "5px";=0A= }=0A= =0A= function populatePage(formName)=0A= {=0A= if (formName.Page.value =3D=3D '')=0A= {=0A= formName.Page.value =3D document.location;=0A= }=0A= }=0A= =0A= function equalizeColumnWidth(numFeatures)=0A= {=0A= var numberOfFeatures =3D numFeatures; =0A= // Percentage width of table to use for each column.=0A= var percentPerFeature =3D Math.floor(100 / numberOfFeatures); =0A= // Number of columns in total. Content cols + seperators. =0A= =0A= document.writeln("");=0A= for(var i =3D 0; i < numberOfFeatures; i++)=0A= { =0A= document.writeln(' 3D"blank"

');=0A= }=0A= document.writeln("");=0A= }=0A= =0A= function old_equalizeColumnWidth(numFeatures)=0A= {=0A= var numberOfFeatures =3D numFeatures; =0A= // Percentage width of table to use for each column.=0A= var percentPerFeature =3D Math.floor(100 / numberOfFeatures); =0A= // Number of columns in total. Content cols + seperators. =0A= =0A= if(debug)=0A= {=0A= alert("Number of feature boxes: " + numberOfFeatures + "\nPercent per = feature: " + percentPerFeature);=0A= }=0A= =0A= document.writeln("");=0A= for(var i =3D 0; i < numberOfFeatures; i++)=0A= { =0A= if (netscape4 =3D=3D false)=0A= {=0A= document.writeln(' 3D"blank"

'); =0A= }=0A= }=0A= document.writeln("");=0A= }=0A= =0A= function writeFBoxCell()=0A= {=0A= if(first)=0A= {=0A= document.write('');=0A= }else=0A= {=0A= document.write('');=0A= }=0A= numFeatures ++;=0A= }=0A= =0A= =0A= //=0A= // escape apostrophe characters within a string=0A= //=0A= function encode(str)=0A= {=0A= out =3D '';=0A= =0A= for (a =3D 0; a < str.length; a++)=0A= {=0A= c =3D str.charAt(a);=0A= =0A= if (c =3D=3D "'")=0A= {=0A= out +=3D '\\';=0A= }=0A= =0A= out +=3D c;=0A= }=0A= =0A= return out;=0A= }=0A= =0A= =0A= //=0A= //=0A= //=0A= function escapeEntities(str)=0A= {=0A= while (str.indexOf("'") > -1)=0A= {=0A= pos =3D str.indexOf("'");=0A= str =3D str.substr(0, pos) + '\\\'' + str.substr(pos + 6);=0A= }=0A= =0A= return str;=0A= }=0A= =0A= =0A= // new popup function less intrusive just uses the DOM to pickup links = with an exwin class.=0A= // currently implemented for Figure popups on D&T homepage.=0A= =0A= function exLinks()=0A= {=0A= if (document.getElementById)=0A= {=0A= var aObject =3D document.getElementsByTagName("a");=0A= for (var x=3D0; x" + = liels[j].innerHTML + "

You do not have = anything saved in this menu.

";=0A= else=0A= tmpinnerhtml +=3D "

" = + liels[j].innerHTML + "

"; =0A= } =0A= } else {=0A= //setup var to see if more is required=0A= var more =3D (subnodeslength < lilength) ? true : = false; =0A= var flag =3D true;=0A= for (var j=3D0; j" + liels[j].innerHTML + = "";=0A= } else if (j > lilength-3){=0A= if (j =3D=3D lilength-2){=0A= var url =3D liels[j].innerHTML.split('"')[1];=0A= tmpinnerhtml +=3D "

" + liels[j].innerHTML + "

";=0A= } else {=0A= tmpinnerhtml +=3D "

" + liels[j].innerHTML + = "

"; =0A= } =0A= } =0A= }=0A= // set last two menu items to have no rollover and = a border at the top =0A= }=0A= menu.childNodes[x].childNodes[y].innerHTML =3D = tmpinnerhtml;=0A= // set default menu elements with diff style=0A= if (flag){=0A= if (more){=0A= liels[liels.length-3].style.borderTop =3D "1px solid = #DDDDDD";=0A= liels[liels.length-3].className =3D "noroll";=0A= liels[liels.length-2].style.borderTop =3D "1px solid = #DDDDDD";=0A= liels[liels.length-2].className =3D "noroll";=0A= liels[liels.length-1].className =3D "noroll";=0A= more =3D false;=0A= } else {=0A= liels[liels.length-2].style.borderTop =3D "1px solid = #DDDDDD";=0A= liels[liels.length-2].className =3D "noroll";=0A= liels[liels.length-1].className =3D "noroll";=0A= } =0A= flag =3D false; =0A= } =0A= =0A= // set sub menu title for the msnu=0A= liels[0].className =3D "hoverTitle";=0A= // apply rollover functions to hide/show sub menus=0A= if (classname =3D=3D "menuDOM"){=0A= menu.childNodes[x].onmouseover =3D function(){=0A= // safari doesnt handle auto in absoulte = positioning correctly so this code makes the menus display correctly.=0A= if (navigator.userAgent.indexOf("Safari") !=3D -1){=0A= if(!window.devicePixelRatio) {=0A= this.getElementsByTagName("UL")[0].style.marginTop =3D "20px";=0A= this.getElementsByTagName("UL")[0].style.marginLeft =3D "0";=0A= }=0A= }=0A= this.className =3D"menuhover domArrowOver";=0A= if(document.all) = this.getElementsByTagName("iframe")[0].style.height=3Dthis.getElementsByT= agName("ul")[0].offsetHeight;=0A= }=0A= menu.childNodes[x].onmouseout=3Dfunction() {=0A= this.className =3D "domArrowOut";=0A= }=0A= }=0A= =0A= if(document.all) {=0A= var newIframe =3D document.createElement("iframe");=0A= newIframe.style.filter =3D = "progid:DXImageTransform.Microsoft.Alpha(style=3D0,opacity=3D0)";=0A= menu.childNodes[x].appendChild(newIframe);=0A= }=0A= =0A= } =0A= }=0A= // deletes the sub menus on the IEMAC as they have a = background bug, will still remain on NS6=0A= if ((navigator.userAgent.indexOf("Mac") !=3D -1) && = (navigator.userAgent.indexOf("MSIE") !=3D -1)){=0A= menu.childNodes[x].innerHTML =3D = menu.childNodes[x].innerHTML.split(""=0A= var menu =3D document.all["menu"].children[0];=0A= menu.style.marginBottom =3D "-3px";=0A= for (var x=3D1; x" + tmp + "";=0A= } else if (x=3D=3D5 || x=3D=3D6){ =0A= tmptable +=3D "" + tmp + = "";=0A= } else {=0A= tmptable +=3D "" + tmp + = "";=0A= }=0A= if (x =3D=3D (menu.children.length-1)){=0A= tmptable +=3D ""; =0A= }=0A= } else {=0A= var tmp =3D menu.children[x].innerHTML.split("" + tmp + = "";=0A= } else if (x=3D=3D2) {=0A= tmptable +=3D "" + tmp + = "";=0A= }=0A= }=0A= }=0A= menu.innerHTML =3D tmptable;=0A= }=0A= };=0A= =0A= var menuloadedflag =3D true;=0A= =0A= =0A= var time =3D new Date();=0A= //@@@DM It was anoying me this error =0A= var ordval=3D (time.getTime());=0A= ------=_NextPart_000_0000_01C9474D.9BD6CF90 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://download.interscience.wiley.com/freeflow/js/journalhome.js //=0A= // Homepage links format:=0A= // homepagelinks[i][0] =3D location=0A= // homepagelinks[i][1] =3D currenthref=0A= // homepagelinks[i][2] =3D type: "e" =3D end of line, "s" =3D separator, = "" =3D normal=0A= //=0A= var writeLinksTraceOn =3D false;=0A= function writeJournalLinks(filename, oid)=0A= {=0A= var url =3D new String(document.location);=0A= var urlpathinfo =3D "";=0A= var pathinfomatch =3D false;=0A= =0A= // Find the pathinfo in the URL - need it later (probably)=0A= //=0A= // Both url and currenthref are expected to be of the form:=0A= // .....//[/]=0A= //=0A= =0A= urlindex =3D url.indexOf("jabout");=0A= if (urlindex =3D=3D -1)=0A= {=0A= urlindex =3D url.indexOf("mrwhome");=0A= }=0A= if (urlindex =3D=3D -1)=0A= {=0A= urlindex =3D url.indexOf("collectionhome");=0A= }=0A= if (urlindex =3D=3D -1)=0A= {=0A= urlindex =3D url.indexOf("bookhome");=0A= }=0A= =0A= if (urlindex !=3D -1) // If found a known CGI name....=0A= {=0A= // We needs a pathinfo match.....=0A= pathinfomatch =3D true;=0A= =0A= // Find the end of the cgi-name=0A= urlindex =3D url.indexOf("/", urlindex + 1);=0A= =0A= // Look for the start of pathinfo=0A= urlindex =3D url.indexOf("/", urlindex + 1);=0A= =0A= if (urlindex !=3D -1)=0A= {=0A= urlindex1 =3D url.indexOf("?", urlindex + 1);=0A= =0A= if(urlindex1 !=3D -1){=0A= urlpathinfo =3D url.substring(urlindex + 1, urlindex1);=0A= writeLinksTrace("urlpathinfo: " + urlpathinfo); 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3D"Utility

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Annals=20 of the New York Academy of Sciences

ISSN: 1749-6632 (Online)

ISSN: 0077-8923 (Print)

Volume=20 1142, Issue 1, 2008.

Pages: 108=96132

Tables: TABLE1

List of=20 Images

Abstract=20 Only

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3D"About

Online ISSN: = 1096-9896 Print ISSN: 0022-3417
The Journal of = Pathology
Volume 214, Issue 3, 2008. Pages: 328-336

Copyright =C2=A9 2007 Pathological Society of Great = Britain and Ireland. Published by John Wiley & Sons, Ltd.

'); } =0A= function copyright(hwnd) {var title =3D pagetitle(); = hwnd.document.write(title.bold() + '
Copyright © 2008 New York = Academy of Sciences

'); } =0A= function imagelink(hwnd, iname) {if (iname.indexOf(' ') > -1) {var = images =3D iname.split(' ');for (var i =3D 0; i < images.length; ++i) = {hwnd.document.write('

');}} = else {hwnd.document.write('

');}}=0A= function otherlinks(hwnd, iname, size) { hwnd.document.write('View List of Images = '); hwnd.document.write('

'); } =0A= =0A= =0A= function caption_f1(hwnd) {hwnd.document.write('Figure = 1. Genetic alterations in glioblastoma. Secondary GBM can = develop from malignant transformation of lower-grade astrocytomas = (low-grade astrocytoma [WHO grade II] or anaplastic astrocytoma [WHO = grade III]), whereas the more common type, primary GBM, develops without = antecedent lower-grade tumors. Genetic analyses reveal common and = differential molecular aberrations between primary and secondary GBMs. = No single genetic mutation represents malignant astrocytomas, indicating = the inherent genetic heterogeneity of these tumors. Therapeutic agents = targeting only single genetic/molecular pathways are less likely to = achieve tumor control in a broad range of patients.'); }=0A= function display_f1(size) { var i =3D new Array(); i[0] =3D 'nf1'; i[1] = =3D 'nf1'; var hwnd =3D newfigwin(); dochead(hwnd, ''); copyright(hwnd); = otherlinks(hwnd, 'f1', size); imagelink(hwnd, i[size]); = caption_f1(hwnd); doctail(hwnd); hwnd.document.close(); hwnd.focus(); }=0A= function caption_f2(hwnd) {hwnd.document.write('Figure = 2. Signal transduction pathways and designer drugs. = Glioblastoma cells and associated endothelial cells often have = constitutive activation of the pathways of several growth factor = receptors such as EGFR, VEGFR, and platelet-derived growth factor = receptor (PDGFR). Each growth factor family consists of several members = for which cognate receptors are transmembrane glycoproteins associated = with protein tyrosine kinase activity. Ligand binding to receptors = induces receptor dimerization and phosphorylation (P). This receptor = activation permits the binding of adaptor proteins such as growth factor = receptor–bound 2 (Grb2)/son of sevenless (SOS) and induces the = activity of many intracellular signal transduction pathways that = regulate gene transcription of essential cellular proteins contributing = to malignancy. Several points in these cascades are the targets of = therapies in development for malignant glioma, some of which are shown. = Signaling molecules might include RAS, RAF, mitogen-activated protein = extracellular-regulated kinase (MEK), extracellular regulated kinase = (ERK; also termed mitogen-activated protein kinase [MAPK]), = phosphatidylinositide-3-kinase (PI3K), AKT, mammalian target of = rapamycin (mTOR), and protein kinase C (PKC). Several points in these = cascades are the targets of therapies in development for malignant = gliomas, some of which are shown. GDP, guanine diphosphate; GTP, guanine = triphosphate; HDAC, histone deacetylase; PIP₂, = phosphatidylinositol (4,5) bisphosphate; PIP₃, = phosphatidylinositol (3,4,5) trisphosphate; PLC, phospholipase C; PTEN, = phosphatase and tensin homolog. (Adapted from Sathornsumetee et = al.⁵)'); }=0A= function display_f2(size) { var i =3D new Array(); i[0] =3D 'nf2'; i[1] = =3D 'nf2'; var hwnd =3D newfigwin(); dochead(hwnd, ''); copyright(hwnd); = otherlinks(hwnd, 'f2', size); imagelink(hwnd, i[size]); = caption_f2(hwnd); doctail(hwnd); hwnd.document.close(); hwnd.focus(); }=0A= function caption_f3(hwnd) {hwnd.document.write('Figure = 3. Strategies to improve effectiveness of designer drugs. = ABCG2, ATP-binding cassette protein G2; BBB, blood–brain barrier; = BCRP, breast cancer resistance protein; CED, convection-enhanced = delivery.'); }=0A= function display_f3(size) { var i =3D new Array(); i[0] =3D 'nf3'; i[1] = =3D 'nf3'; var hwnd =3D newfigwin(); dochead(hwnd, ''); copyright(hwnd); = otherlinks(hwnd, 'f3', size); imagelink(hwnd, i[size]); = caption_f3(hwnd); doctail(hwnd); hwnd.document.close(); hwnd.focus(); }=0A= =0A= =0A= function imagelist() {var hwnd =3D newfigwin(); dochead(hwnd, 'List of = Images - '); copyright(hwnd); =0A= hwnd.document.write('');=0A= =0A= =0A= hwnd.document.write('');=0A= hwnd.document.write('');=0A= hwnd.document.write('');hwnd.document.write('

	'); =0A= caption_f1(hwnd); hwnd.document.write(' [Normal View]

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Volum= e=20 1142, Issue The Year in Neurology 2008, Pages = 108-132

Published Online: 23 Oct 2008

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Designer Therapies for Glioblastoma=20 Multiforme

Sith=20 Sathornsumetee ^a and Jeremy N. Rich=20 ^b

^a Neuro-Oncology = Program,=20 Departments of Medicine (Neurology) and Pathology, Faculty of = Medicine,=20 Siriraj Hospital, Mahidol University, Bangkok, Thailand ^b Departments of = Medicine,=20 Surgery, Pharmacology, and Cancer Biology, Preston Robert Tisch = Brain=20 Tumor Center, Duke University Medical Center, Durham, North = Carolina,=20 USA

Address for correspondence: = Jeremy N. Rich,=20 M.D., Departments of Medicine, Surgery, Pharmacology, and Cancer = Biology,=20 Preston Robert Tisch Brain Tumor Center, Duke University Medical = Center,=20 DUMC 2900, Durham, NC 27710. Voice: 919-681-1693; fax: = 919-684-6514. rich0001@mc.duke.edu=20

Copyright =A9 2008 New York Academy of = Sciences

KEYWORDS

brain tumor =95 glioblastoma =95 glioma =95 = targeted therapy=20 =95 kinase inhibitors

ABSTRACT

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Primary brain tumors account for less than 2% of = all cancers=20 in adults; however, they are often associated with neurologic = morbidity=20 and high mortality. Glioblastoma multiforme (GBM) has been a focus = of new=20 therapy development in neurooncology because it is the most common = primary=20 brain tumor in adults. Standard-of-care therapy for newly = diagnosed GBM=20 includes surgical resection, radiotherapy, and temozolomide, = administered=20 both during and after radiotherapy. However, most patients develop = tumor=20 recurrence or progression after this multimodality treatment. = Repeat=20 resection and stereotactic radiosurgery upon recurrence may = improve=20 outcome only in selected patients. Most salvage chemotherapies = offer only=20 palliation. Recent advances in our understanding of the molecular=20 abnormalities of GBM have generated new therapeutic venues of = molecularly=20 targeted agents (designer drugs) against key components of = cellular=20 pathways critical for cancer initiation and maintenance. Such = drugs may=20 offer the potential advantage to increase therapeutic efficacy and = decrease systemic toxicity compared with traditional cytotoxic = agents.=20 Nonetheless, first-generation targeted agents have failed to = demonstrate=20 survival benefits in unselected GBM patient populations. Several=20 mechanisms of treatment failure of the first-generation designer = drugs=20 have been proposed, whereas new strategies have been developed to = increase=20 effectiveness of these agents. Here we will discuss the recent = development=20 and the strategies to optimize the effectiveness of designer = therapy for=20 GBM.

DIGITAL OBJECT IDENTIFIER (DOI)

10.1196/annals.1444.009 About = DOI

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Introduction

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Glioblastoma multiforme (GBM) is the most common = primary=20 brain tumors in adults. The incidence of GBM is three per 100,000=20 person-years in the United States.¹=20 According to the World Health Organization (WHO) classification, = GBM is=20 characterized as grade IV astrocytoma with pathologic hallmarks of = necrosis and vascular proliferation. GBMs represent highly lethal = cancers=20 associated with significant morbidity and mortality. In a Swiss=20 population-based study, the survival rate of patients with newly = diagnosed=20 GBM was approximately 18% at 1 year and only 3% at 2 = years.²=20 Despite available state-of-the-art multimodality treatments, the = median=20 survival of GBM patients is 12=9615 months.³=20 Favorable prognostic factors include young age, absent or minimal=20 neurological signs, complete surgical resection, and good = performance=20 status.⁴=20 Current standard-of-care therapies include surgery; radiation; and = more=20 recently, concurrent and adjuvant temozolomide. Recent elucidation = of=20 molecular abnormalities underlying glioma pathogenesis has led to = several=20 new therapeutic approaches, which include targeting specific = oncogenic=20 signaling elements by molecularly targeted therapy (designer = drugs),=20 immunotherapy, and gene therapy.⁵=20 Also, strategies to enhance delivery of therapeutic agents into = the=20 central nervous system, which include local polymer = administration,=20 convection-enhanced delivery (CED), and other new delivery systems = such as=20 nanoparticles, may increase therapeutic efficacy. In this review, = we will=20 discuss the recent advances in the development of new targeted = therapy in=20 GBM.

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Current Standard-of-Care Treatment = for GBM

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Most GBM patients, after histological diagnosis, = usually=20 undergo multimodality treatments including surgical resection, = radiation,=20 and chemotherapy.⁶=20 Gross or near-total resection, if feasible, significantly improves = survival.⁷=20 Radiation therapy has been the mainstay treatment for GBM for = decades=20 because it offers unequivocal survival benefit.⁸=20 Adjuvant chemotherapy had not demonstrated significant clinical = benefit=20 until recently when Stupp et al. reported = that=20 concurrent and adjuvant temozolomide (TMZ) significantly improved = survival=20 of GBM patients without degradation in quality of life in an=20 international, multicentered trial.^9,10=20 This pivotal phase III trial of 573 patients randomized to either=20 radiation (external radiation therapy [XRT]) alone or radiation = therapy=20 with concurrent TMZ followed by monthly adjuvant TMZ for six = cycles=20 (XRT-TMZ/TMZ) demonstrated a 2-year survival rate of 24% for = XRT-TMZ (75=20 mg/m² of body surface area/day for 42 = consecutive=20 days)/TMZ (150=96200 mg/m²/day for 5 days = every=20 28-day cycle) group compared with 10% for the XRT group. The = median=20 survival was 14.6 months for the XRT-TMZ/TMZ group compared with = 12.1=20 months for the XRT group.⁹=20 Patients with treatment failure after XRT received TMZ, so the = study was=20 powered to specifically test the effects of chemoradiation rather = than=20 adjuvant chemotherapy. TMZ adds clinical benefit without = significant=20 impairment of patient quality of life.¹⁰=20 Also, a recent economic analysis in Europe has shown that although = the TMZ=20 cost is high, its costs per life-year gained are comparable to = accepted=20 first-line treatment with chemotherapy in patients with other=20 cancers.¹¹=20 Therefore, TMZ administered concurrently during XRT and after XRT, = using=20 adjuvant monthly cycles, has become a new standard-of-care = treatment for=20 GBM. Although TMZ significantly prolongs survival for GBM = patients, the=20 degree of benefit is modest. More strategies to enhance the = efficacy of=20 this regimen are clearly needed. Alternative dosing schedules; = extended=20 length of therapy; delivery enhancement; addition of agents to = prevent or=20 rescue TMZ resistance; and combination of TMZ with other = modalities such=20 as targeted therapeutics, gene therapy, or immunotherapy may = improve=20 treatment efficacy.

Most GBM patients develop recurrence or = progression after=20 the current standard treatments.¹²=20 Surgical re-resection may increase survival in selected patients = with=20 recurrent GBM, mostly in symptomatic patients with large mass=20 effect.¹²=20 Locoregional treatments such as chemotherapy wafer,¹³=20 stereotactic irradiation,¹⁴=20 radioimmunoconjugates,¹⁵=20 and conjugated biological toxins¹⁶=20 may limit systemic toxicity and improve local tumor control = because most=20 GBMs recur within 2=963 cm of the primary tumor or resection=20 site.¹⁷=20 These new locoregional treatments are currently under clinical=20 investigation.

Unfortunately, available salvage chemotherapies = after=20 progression are ineffective, with "successes" demonstrating a = 6-month=20 progression-free survival (PFS-6) rate of 15% for = GBM.¹⁸=20 PFS-6 has recently become a more widely acceptable primary = endpoint for=20 phase II trials in malignant glioma because it correlates with = overall=20 survival.^19,20=20 Because of the lack of effective chemotherapies, new therapies = targeting=20 underlying pathogenesis of malignant gliomas are obviously=20 needed.

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Genetic Alterations in GBM

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GBM, like other cancers, exhibits characteristic = malignant=20 phenotypes, including self-sustained proliferation, resistance to=20 apoptotic stimuli, evasion of external growth control and=20 immunosurveillance, tissue invasion, and ability to form and = sustain new=20 blood vessels.⁵=20 GBM is genetically heterogeneous between patients and within=20 tumors.^21,22=20 Furthermore, evolving molecular aberrations from dynamic genetic=20 instability are also characteristic for GBM. Nevertheless, = frequent=20 genetic alterations that maintain malignant phenotypes of tumors = have been=20 described. Most GBMs (90%) are diagnosed without antecedent = lower-grade=20 tumor=97termed primary or de novo GBM, = whereas=20 secondary GBM has clinical evidence of transformation from = lower-grade=20 gliomas.²³=20 Low-grade astrocytomas (WHO grade II) often display disruption of = tumor=20 suppressor gene TP53 and overexpression of=20 platelet-derived growth factor (PDGF) ligands and receptors. In = response=20 to genotoxic stress, the TP53 gene = functions to=20 induce cell cycle arrest, apoptosis, and DNA repair. Inactivation = of TP53 is associated with abnormal cell division = and=20 neoplastic transformation. Progression to anaplastic astrocytoma = involves=20 accumulation of other genetic alterations of associated cell cycle = regulatory pathways, including deletion or mutations of = cyclin-dependent=20 kinase inhibitor p16^INK4A/CDKN2A or the=20 retinoblastoma susceptibility locus 1 (pRB1), as well as = amplification or=20 overexpression of cyclin-dependent kinase (CDK)4/6=20 and human double minute 2 (HDM2). = Transformation to=20 GBM (i.e., secondary GBM) is associated with deletion of = chromosome 10,=20 which includes the tumor suppressor phosphatase and tensin homolog = (PTEN). Primary GBMs tend to occur more often in = older=20 patients than secondary GBMs and primary GBMs share some genetic=20 abnormalities with secondary GBMs such as loss of PTEN, deletion or mutation of cyclin-dependent = kinase=20 inhibitors p16^INK4A (which shares a locus = with=20 p14^ARF on chromosome 9), and amplification = of=20 HDM2 or CDK4. = However,=20 additional molecular changes distinguish primary and secondary = GBMs.=20 Epidermal growth factor receptor (EGFR) = amplification=20 is more common in primary GBMs, whereas TP53 loss is=20 a genetic hallmark of low-grade astrocytoma and secondary GBMs (Fig.=20 1). Transcriptional profiling has demonstrated common and = differential=20 gene expression between primary and secondary GBMs.²⁴=20 Primary GBM=96associated genes involve stromal and mesenchymal = stem=20 cell=96like properties, whereas secondary GBM=96associated genes = commonly=20 involve mitotic cell cycle components.

=20

= Figure 1. = Genetic=20 alterations in glioblastoma. Secondary GBM can develop from=20 malignant transformation of lower-grade astrocytomas = (low-grade=20 astrocytoma [WHO grade II] or anaplastic astrocytoma [WHO = grade=20 III]), whereas the more common type, primary GBM, develops = without=20 antecedent lower-grade tumors. Genetic analyses reveal = common and=20 differential molecular aberrations between primary and = secondary=20 GBMs. No single genetic mutation represents malignant = astrocytomas,=20 indicating the inherent genetic heterogeneity of these = tumors.=20 Therapeutic agents targeting only single genetic/molecular = pathways=20 are less likely to achieve tumor control in a broad range of = patients.

[Normal View=20 ]

Some of these genetic abnormalities deregulate = signal=20 transduction pathways, a communication network of regulatory = molecules=20 within the cell, controlling cellular processes contributing to = normal=20 homeostasis and malignancy. For example, amplification or mutation = of EGFR=20 can increase activity of the RAS mitogen-activated protein kinase = (MAPK)=20 and phosphatidylinositide-3-kinase (PI3K)/AKT pathways. PI3K/AKT=20 overactivity may also result from loss of PTEN, a negative = regulator of=20 PI3K function. Understanding these molecular and genetic = abnormalities has=20 led to a rational development of molecularly targeted (designer) = therapies=20 in GBM.

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Designer Drugs Targeting Signal = Transduction=20 Pathway

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Signal transduction pathways are regulated by = several growth=20 factors, hormones, and cytokines. Most receptors for growth factor = pathways (e.g., EGF, PDGF, and vascular endothelial growth factor = [VEGF])=20 are associated with tyrosine kinase activity and therefore share = common=20 mechanisms of pathway activation. Overexpression or mutations of = receptors=20 and intracellular downstream effectors have been identified in = malignant=20 gliomas, leading to constitutive activation of signaling pathways, = resulting in uncontrolled cellular proliferation, survival, = invasion, and=20 secretion of angiogenic factors (Fig.=20 2). New treatments have been designed to target molecules in = these=20 signaling pathways with the goal to increase specific efficacy and = minimize toxicity.²⁵=20 Monoclonal antibodies and low-molecular-weight inhibitors are = among common=20 targeted therapeutics used in cancer. Monoclonal antibodies are=20 multivalent proteins engineered to have high selectivity and = affinity to=20 antigenic epitopes. In brain tumors, most monoclonal antibodies = are=20 delivered locally to tumor or resection cavity because systemic=20 administration may not achieve adequate delivery owing to = restriction by=20 the blood=96brain barrier. Modulation of blood=96brain barrier = integrity may=20 overcome this challenge. Also, monoclonal antibodies that can = function on=20 the abluminal side of blood vessels (such as a neutralizing VEGF = antibody,=20 bevacizumab) without a need to traverse the blood=96brain barrier = may be=20 effective in the treatment of brain tumors.

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= Figure 2. = Signal=20 transduction pathways and designer drugs. Glioblastoma cells = and=20 associated endothelial cells often have constitutive = activation of=20 the pathways of several growth factor receptors such as = EGFR, VEGFR,=20 and platelet-derived growth factor receptor (PDGFR). Each = growth=20 factor family consists of several members for which cognate=20 receptors are transmembrane glycoproteins associated with = protein=20 tyrosine kinase activity. Ligand binding to receptors = induces=20 receptor dimerization and phosphorylation (P). This receptor = activation permits the binding of adaptor proteins such as = growth=20 factor receptor=96bound 2 (Grb2)/son of sevenless (SOS) and = induces=20 the activity of many intracellular signal transduction = pathways that=20 regulate gene transcription of essential cellular proteins=20 contributing to malignancy. Several points in these cascades = are the=20 targets of therapies in development for malignant glioma, = some of=20 which are shown. Signaling molecules might include RAS, RAF, = mitogen-activated protein extracellular-regulated kinase = (MEK),=20 extracellular regulated kinase (ERK; also termed = mitogen-activated=20 protein kinase [MAPK]), phosphatidylinositide-3-kinase = (PI3K), AKT,=20 mammalian target of rapamycin (mTOR), and protein kinase C = (PKC).=20 Several points in these cascades are the targets of = therapies in=20 development for malignant gliomas, some of which are shown. = GDP,=20 guanine diphosphate; GTP, guanine triphosphate; HDAC, = histone=20 deacetylase; PIP₂, = phosphatidylinositol=20 (4,5) bisphosphate; PIP₃,=20 phosphatidylinositol (3,4,5) trisphosphate; PLC, = phospholipase C;=20 PTEN, phosphatase and tensin homolog. (Adapted from = Sathornsumetee=20 et al.⁵)=20

[Normal View=20 ]

Low-molecular-weight kinase inhibitors are often = ATP=20 mimetics that display affinity for the ATP binding site in the = kinase=20 domains of growth factor receptors and intracellular signaling = elements.=20 The specific targeting of single kinases has proven challenging = because=20 the ATP site is highly conserved in the kinase genes. The initial = desire=20 to limit off-target effects of these inhibitors has been tempered = by the=20 success of less selective inhibitors (previously called "dirty" = but now=20 retermed "multiselective") in clinical trials (e.g., sunitinib and = sorafenib). Many low-molecular-weight kinase inhibitors have = undergone=20 preclinical and clinical investigation in brain tumors, mostly = malignant=20 gliomas. Because of their small size, these low-molecular-weight=20 inhibitors might have advantage for central nervous system (CNS) = delivery.=20 However, several other factors such as physiological variables; = polarity=20 of drugs; and active efflux transporter at the blood=96brain,=20 blood=96cerebrospinal fluid, or blood=96tumor barrier might limit = CNS and=20 subsequent tumor delivery. Strategies to enhance delivery of = kinase=20 inhibitors are needed.

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Inhibition of Growth Factor = Signaling=20 Pathways

Relevant growth factor pathways in malignant = gliomas include=20 EGF, PDGF, VEGF, insulin-like growth factor (IGF), fibroblast = growth=20 factor, and hepatocyte growth factor/scatter factor (HGF/SF). In = GBM,=20 several growth factor receptors (e.g., EGFR, VEGFR, PDGFR) are=20 overexpressed or mutated, leading to activation of downstream = signaling=20 pathways with subsequent stimulation of proliferation, survival, = invasion,=20 and secretion of angiogenic factors. Kinase inhibitors and = monoclonal=20 antibodies of these ligands or receptors have been developed in = clinical=20 trials for malignant glioma.

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Epidermal Growth = Factor=20 Pathway

EGFR is amplified in approximately half of GBMs = and is=20 overexpressed in many malignant gliomas independent of = amplification=20 status.²⁶=20 Also, the frequent overexpression of several EGFR mutants, = including a=20 variant with loss of exons 2=967 (EGFRvIII) resulting in the loss = of=20 extracellular ligand binding but constitutive activation, suggests = that=20 EGFR is a key factor in gliomagenesis and provides a rationale for = the use=20 of EGFR targeted therapies in these patients.²⁷=20 Two kinase inhibitors of EGFR, erlotinib (Tarceva, OSI-774; = Genentech,=20 South San Francisco, CA) and gefitinib (Iressa, ZD1839; = AstraZeneca,=20 Wilmington, DE), have been evaluated in malignant gliomas. In the = first=20 phase II trial of gefitinib for recurrent GBM, the median = event-free=20 survival was only 8.1 weeks, and no radiographic responses were = observed,=20 although nine of the 53 patients (17%) remained event free for at = least 6=20 months.²⁸=20 Another phase II trial from Italy has confirmed the = ineffectiveness of=20 gefitinib in high-grade glioma patients.²⁹=20 In a published phase I trial, erlotinib as monotherapy or in = combination=20 with temozolomide demonstrated a 14% partial response (PR; a = >50%=20 decrease in maximal area on radiographic evaluation) rate and a = PFS-6 of=20 11%.³⁰=20 Other phase II trials of erlotinib have demonstrated a PR rate of = 6%=9625%=20 with modest effect on progression-free or overall survival=20 rates.^31,32=20 Therefore, erlotinib appears to be more effective against = malignant=20 gliomas than gefitinib for radiographic response rate, but both = have no=20 clear effect on survival. Small fractions of lung cancer patients = display=20 remarkable responses to EGFR inhibitors that are associated with = mutations=20 in the kinase regions of EGFR that create a constitutively active = receptor=20 kinase.³³=20 These radiographic responses and kinase mutations have not been = detected=20 in glioma patients.^34=9636=20 However, two retrospective studies demonstrated that high = expression of=20 wild-type EGFR and low levels of phosphorylated Akt in one=20 study³⁷=20 and coexpression of EGFRvIII and wild-type PTEN in another=20 study³⁸=20 were associated with increased radiographic response to EGFR = kinase=20 inhibitors (erlotinib and gefitinib). In contrast, a relatively = large (110=20 patients) phase II randomized study of erlotinib versus = temozolomide or=20 carmustine in recurrent malignant gliomas conducted by the = European=20 Organization for Research and Treatment of Cancer (EORTC) = demonstrated no=20 radiographic response or survival benefit of erlotinib, and the = expression=20 of EGFR, EGFRvIII, or PTEN was not correlated with survival=20 advantage.³⁹=20 In fact, coexpression of EGFRvIII and wild-type PTEN was = associated with=20 decreased overall and progression-free survival.³⁹=20 The discrepancy observed among these biomarker studies may derive = from=20 different substrates and techniques of biomarker assessment, small = sample=20 size, and varied radiographic response criteria. Clearly, = prospective=20 validation with a standardized biomarker assay among different=20 laboratories is required to resolve this controversy. Until then, = routine=20 use of gefitinib or erlotinib, even in patients with EGFRvIII and=20 wild-type PTEN coexpression, should be approached = conservatively.

Irreversible EGFR inhibitors have demonstrated = superior=20 efficacy in preclinical studies against cancer harboring EGFRvIII = to=20 reversible EGFR kinase inhibitors such as gefitinib and=20 erlotinib.⁴⁰=20 Clinical development of irreversible EGFR kinase inhibitors in = malignant=20 gliomas with EGFRvIII mutation appears warranted. In addition to=20 small-molecule inhibitors, a monoclonal antibody against EGFR, = cetuximab=20 (Erbitux; Imclone Systems, New York, NY), has demonstrated = preclinical=20 antitumor activity as a single agent and combinatorial benefit = with=20 radiation against EGFR-amplified GBM.⁴¹=20 Despite the concern of limited CNS delivery, as described in the=20 preceding, cetuximab is undergoing clinical evaluation in patients = with=20 recurrent GBMs either alone or in combination with other targeted=20 therapies such as bevacizumab.⁴²

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PDGF Pathway =

PDGF signaling is important for growth and = angiogenesis of=20 gliomas. Infusion of PDGF in rodent brains induces neural stem = cells to=20 form glioma-like growths.⁴³=20 Imatinib mesylate (Gleevec, STI571; Novartis Pharmaceuticals, East = Hanover, NJ), an inhibitor of PDGFR, c-kit, and bcr-abl kinases, = exhibited=20 antiglioma activity in preclinical studies.⁴⁴=20 However, imatinib monotherapy failed to demonstrate benefit for = malignant=20 glioma patients in several phase I/II trials.⁴⁵=20 Nonetheless, imatinib mesylate in combination with hydroxyurea has = demonstrated promising, albeit modest, antitumor activity in a = patient=20 series,⁴⁶=20 which was subsequently confirmed by a phase II study.⁴⁷=20 In this trial of 33 patients with recurrent GBMs, the radiographic = response rate was 9% with a PFS-6 of 27%. Another study confirmed = the=20 antitumor activity of this regimen in recurrent grade 3 malignant = glioma=20 patients.⁴⁸=20 The treatment combination was well tolerated. The mechanism = contributing=20 to combinatorial benefit of imatinib and hydroxyurea remains to be = elucidated. Because of the encouraging results of imatinib = mesylate plus=20 hydroxyurea, several combinations of imatinib mesylate with other=20 chemotherapies such as temozolomide are under clinical = investigation. A=20 recently published phase I trial of imatinib mesylate in = combination with=20 temozolomide has revealed the safety and tolerability with some = hints of=20 activity.⁴⁹=20 Further evaluation in larger studies is needed.

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VEGF Pathway =

Angiogenesis, the creation of new blood vessels = from=20 preexistent blood vessels, is a pathologic hallmark of cancer. For = tumor=20 growth beyond approximately 2 mm³, a new = network=20 of blood vessels must be constructed for nutrient and oxygen = supply (the=20 "angiogenic switch").⁵⁰=20 This angiogenesis dependence of tumor relative to normal organs = provides=20 an opportunity to develop specific tumor-targeted therapy. = Expression of=20 VEGF, a key regulator of tumor angiogenesis, increases with the = grade of=20 gliomas, whereas microvessel density is associated with poor = prognosis in=20 glioma patients.^51,52=20 The VEGF pathway can be targeted at the level of VEGF ligands or = at the=20 level of VEGFR.⁵³

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Targeting VEGF = Ligands=20

Targeting the VEGF pathway has been one the most = exciting=20 focuses in the treatment of malignant gliomas in the past few = years=20 because unprecedented radiographic response and survival benefit = were=20 observed with a VEGF-targeted agent, bevacizumab, in combination = with=20 irinotecan.^54,55=20 Bevacizumab (Avastin; Genentech), a recombinant human neutralizing = monoclonal antibody of VEGF, is the first U.S. Food and Drug=20 Administration=96approved antiangiogenic agent in cancer = treatment.=20 Preclinical studies of A4.6.1, a murine counterpart of = bevacizumab,=20 reduced tumor vascularity, enhanced tumor apoptosis, and prolonged = survival in preclinical studies with a rat intracranial C6 glioma=20 model.⁵⁶=20 A4.6.1 also offered a synergistic effect with radiation therapy in = GBM=20 xenografts.⁵⁷=20 The antitumor mechanism of bevacizumab is unclear. Changes in = vascular=20 structure and function have been reported, including decreased = vessel=20 diameter, density, and permeability in response to treatment. A = reduction=20 in interstitial fluid pressure has also been observed. In some = studies,=20 these improvements resulted in an increase in intratumoral uptake = of=20 chemotherapy because of transient improved vascular function = ("forced=20 normalization"), implying that the most effective use of anti-VEGF = therapy=20 may be in combination with chemotherapy.^58,59=20 Bevacizumab has demonstrated encouraging antitumor activity in = combination=20 with topoisomerase I inhibitor, irinotecan (Camptosar, CPT-11; = Pfizer, New=20 York, NY) in an anecdotal series, which was confirmed in a phase = II trial=20 at Duke University.⁵⁴=20 This combination demonstrated a remarkable radiographic response = rate of=20 63% with a PFS-6 of 32% for GBM and 61% for recurrent anaplastic = gliomas.=20 This regimen was generally well tolerated, with similar side = effects to=20 the use of bevacizumab in other cancers (e.g., hypertension, = changes in=20 renal function). The encouraging radiographic response rates = detected in=20 this initial phase prompted an expansion to include a total of 68 = patients=20 with recurrent malignant gliomas. The PFS-6 for all 68 patients = was 43%=20 for recurrent GBM and 61% for recurrent anaplastic = gliomas.⁵⁵=20 There was only one intracerebral hemorrhage that occurred after 1 = year of=20 treatment. A few patients developed venous thromboembolism and one = patient=20 had an arterial ischemic stroke. Because irinotecan monotherapy = was not=20 associated with survival benefit in several prior clinical trials, = the=20 contribution of irinotecan to antitumor activity of this regimen = is under=20 investigation in a phase II study of bevacizumab versus = bevacizumab plus=20 irinotecan.⁶⁰=20 Preliminary results suggest that patients enjoy greater benefit = from the=20 combination of bevacizumab and irinotecan than from bevacizumab = alone and=20 support the use of anti-VEGF therapy in combination with cytotoxic = agents.⁶⁰=20 Several clinical trials of bevacizumab in combination with = radiation=20 therapy, chemotherapy, or other targeted agents are ongoing.

The radiographic response observed by = contrast-enhanced=20 magnetic resonance imaging with bevacizumab treatment does not = necessarily=20 translate into overall survival benefit because targeting VEGF = alters=20 vascular permeability without necessarily altering the tumor = directly, so=20 several strategies such as metabolic imaging (positron emission = tomography=20 [PET]) and tumor immunohistochemical profiling have been exploited = to=20 define predictive biomarkers. = [¹⁸F]thymidine PET,=20 an imaging biomarker of cell proliferation, was assessed in 21 = malignant=20 glioma patients treated with bevacizumab and = irinotecan.⁶¹=20 Patients with greater than 25% reduction in=20 [¹⁸F]thymidine uptake on PET imaging = ("metabolic=20 response") at 1=962 weeks and 6 weeks after treatment initiation = experienced=20 improved survival. More recently, we have reported that tumor = expression=20 of VEGF, a molecular target of bevacizumab, at the time of = original=20 diagnosis assessed by immunohistochemistry was associated with = increased=20 likelihood of radiographic response but not survival benefit in = malignant=20 astrocytoma patients treated with bevacizumab and = irinotecan.⁶²=20 Tumor hypoxia as measured by high carbonic anhydrase-IX expression = was=20 associated with poor survival outcome in this patient=20 population.⁶²=20 Prospective validation of both imaging and tissue biomarkers for=20 bevacizumab in malignant gliomas is warranted.

In patients with recurrence after initial response = to=20 bevacizumab plus single chemotherapy, continuing bevacizumab and = changing=20 the chemotherapy agent provide disease control only in a few=20 patients.⁶³=20 Also, bevacizumab may alter the recurrence pattern of malignant = gliomas by=20 suppressing enhancing tumor recurrence more effectively than it = suppresses=20 nonenhancing, infiltrative tumor growth.⁶³=20 In addition to its activity in recurrent malignant gliomas, = bevacizumab=20 was also evaluated in newly diagnosed GBM patients as an up-front=20 treatment with radiotherapy and temozolomide.⁶⁴=20 This phase II pilot study demonstrated safety and acceptable = toxicities in=20 the first 10 patients (planned enrollment of 70 patients) with = encouraging=20 antitumor activity.

Another agent that inhibits VEGF by blocking = ligand=96receptor=20 binding is VEGF-trap (Regeneron, Tarrytown, NY).⁶⁵=20 VEGF-trap is a potent soluble decoy receptor of VEGF that = effectively=20 suppresses tumor growth and angiogenesis in preclinical cancer=20 models.⁶⁵=20 VEGF-trap has antiglioma activity as high-dose monotherapy, but it = offered=20 combinatorial benefit even at low dose with radiation therapy in a = subcutaneous human GBM xenograft model.⁶⁶=20 A clinical trial of VEGF-trap in recurrent malignant gliomas is=20 ongoing.

=20

=20

Targeting VEGF = Receptor=20

Preclinical evaluation of VEGFR inhibition by both = monoclonal antibody and kinase inhibitor have demonstrated = efficacy=20 against malignant gliomas. Vatalanib (PTK787/ZK222584; Novartis), = a kinase=20 inhibitor of VEGFR and PDGFR, has demonstrated modest efficacy in=20 multicentered phase I/II trials either alone or in combination = with=20 chemotherapy.^67,68=20 Recently, a phase II trial of cediranib (AZD2171; AstraZeneca), a=20 pan-VEGFR inhibitor, has demonstrated encouraging antiangiogenic = efficacy=20 in GBM patients with radiographic response rate of 56% and APF = (alive and=20 progression-free) at 6 months of 27.6%.⁶⁹=20 Significant increases in plasma VEGF and in placental growth = factor and a=20 decrease in soluble VEGFR-2 were observed during the treatment. In = patients who developed disease progression, plasma angiogenic = profile=20 changes with not only decrease in placental growth factor and = increase in=20 soluble VEGFR-2 levels but also increases in viable circulating=20 endothelial cells, basic fibroblast growth factor, and = stromal-derived=20 factor 1α levels. Also, dynamic contrast=96enhanced magnetic = resonance=20 imaging along with diffusion-weighted and tractographic imaging = were used=20 to monitor the "normalization" phenomenon and clinical response in = GBM=20 patients treated with cediranib.⁶⁹

=20

=20

IGF = Receptor

IGF signaling is important in regulating cell = growth and=20 proliferation.⁷⁰=20 IGF-1R, a receptor tyrosine kinase, has been a prominent target = for cancer=20 therapeutics. A preclinical study demonstrated that an EGFR kinase = inhibitor=96resistant GBM cell line had an upregulation of IGF-1R, = preferentially activating the PI3K pathway, resulting in = proliferative,=20 antiapoptotic, and proinvasive potentials.⁷¹=20 Targeting this resistant cell line with a combination of EGFR and = IGF-1R=20 inhibitors enhanced spontaneous and radiation-induced apoptosis = and=20 reduced tumor invasion. Several therapeutic agents against IGF-1R = have=20 been developed in a preclinical phase.⁷²

=20

=20

HGF Pathway =

HGF/SF is upregulated in many human cancers, = including=20 GBM.⁷³=20 HGF and its cognate receptor tyrosine kinase, c-met, are expressed = on=20 glioma cells, suggesting autocrine and paracrine loops of = activation.=20 HGF/SF-met signaling is associated with tumor cell proliferation,=20 invasion, and angiogenesis, and expression of pathway components = increases=20 with malignant progression.⁷³=20 Neutralizing monoclonal antibodies to HGF/SF as monotherapy and in = combination with temozolomide have demonstrated antitumor activity = in both=20 subcutaneous and orthotopic malignant glioma xenograft=20 models.^74=9679=20 A multicentered phase II trial of AMG-102 (Amgen, Thousand Oaks, = CA), an=20 HGF/SF monoclonal antibody, is ongoing in advanced malignant=20 glioma.

=20

=20

Transforming = Growth Factor β=20 Pathway

Transforming growth factor β (TGF-β) is = a multifunctional=20 cytokine secreted from glioma cells to regulate cell motility, = invasion,=20 immune surveillance, and angiogenesis. Upon binding to TGF-β = ligand, TGF-β=20 receptors (type I and II) become heterodimerized and = phosphorylated to=20 activate downstream effectors in the SMAD family and promote gene=20 transcription. High TGF-β=96SMAD activity levels are present = in aggressive,=20 highly proliferative gliomas and confer poor prognosis in=20 patients.⁸⁰=20 A phase I/II trial of intratumoral AP 12009, an antisense=20 oligodeoxynucleotide specific to TGF-β2, demonstrated good = tolerability=20 and promising antitumor activity with median survival of 47 weeks = for=20 recurrent GBM.⁸¹=20 Several low-molecular-weight inhibitors of TGF-β receptors = have=20 demonstrated antitumor efficacy and induction of antitumor = immunity in=20 preclinical models of gliomas.^82,83=20 These agents might be evaluated in clinical trials as = monotherapies or in=20 combination with other treatment modalities such as chemotherapy = or=20 radiation in patients with malignant gliomas.

=20

=20

Inhibition of Intracellular = Effectors

After growth factor receptor activation, effector = molecules=20 such as RAS, PI3K, and phospholipase C are recruited to the cell=20 membrane.⁸⁴=20 Many gliomas are associated with either activation of these = effector=20 molecules or inactivating mutations of the negative regulators of = these=20 kinases such as PTEN in the PI3K pathway. Sequential activation by = phosphorylation of intracellular effectors along signal = transduction=20 pathways relays important information to regulate cellular = processes=20 contributing to malignancy. Crucial intracellular mediators in = oncogenic=20 pathways include RAF, mitogen-activated protein = extracellular-regulated=20 kinase (MEK), extracellular-regulated kinase (ERK; also termed = MAPK), AKT,=20 and mammalian target of rapamycin (mTOR). A variety of designer = inhibitors=20 of these intracellular effectors have been developed in = preclinical and=20 clinical studies of malignant gliomas.

=20

=20

RAS=96RAF=96MEK=96ERK Pathways=20

RAS encodes small = GTP-binding proteins=20 that regulate many cellular functions such as proliferation,=20 differentiation, cytoskeletal organization, protein trafficking, = and the=20 secretion of angiogenic factors.⁸⁵=20 Gliomas rarely contain oncogenic RAS = mutations;=20 however, they often have high RAS activity due to mutations or=20 overexpression of upstream growth factor receptors. RAS proteins, = like=20 many proteins, undergo posttranslational modification with the = addition of=20 lipids to permit membrane localization. This process, called = prenylation,=20 may involve the addition of either farnesyl or geranylgeranyl = groups.=20 Prenylation is the rate-limiting step in RAS maturation; = therefore,=20 several farnesyltransferase inhibitors have undergone clinical = evaluation=20 as a RAS targeted therapy. Two farnesyltransferase inhibitors, = tipifarnib=20 (Zarnestra, R115777; Johnson & Johnson, New Brunswick, NJ) and = lonafarnib (Sarasar, SCH66336; Schering-Plough, Berkeley Heights, = NJ),=20 have been developed. A phase I/II study of tipifarnib in recurrent = malignant gliomas demonstrated a PFS-6 of 9% in recurrent WHO = grade III=20 gliomas and 12% in recurrent GBMs.⁸⁶=20 In a phase I trial of temozolomide plus lonafarnib, 27% of = patients with=20 prior temozolomide failure had a PR, and the estimated PFS-6 was=20 33%.⁸⁷=20 Downstream from RAS is the RAF=96MEK=96ERK pathway, which = regulates mainly=20 cell proliferation. Activation of ERK is associated with poor = outcome in=20 GBM patients.⁸⁸=20 Thus, targeting the RAF=96MEK=96ERK pathway may be effective in = malignant=20 glioma. A preclinical study of a RAF/VEGFR inhibitor, AAL881 = (Novartis),=20 has demonstrated significant in vitro and = in vivo antiglioma activity.⁸⁹=20 Clinical trials of sorafenib (Nexavar; Bayer, West Haven, CT, and = Onyx,=20 CA), another inhibitor of RAF/VEGFR, in combination with several = other=20 targeted agents are ongoing.

=20

=20

PI3K=96AKT=96mTOR = Pathways=20

PI3K pathways regulate several malignant = phenotypes=20 including antiapoptosis, cell growth, proliferation, and=20 invasion.⁹⁰=20 Activation of PI3K pathways is associated with poor prognosis in = glioma=20 patients.⁹¹=20 Loss of PTEN is a common genetic feature in = GBM that=20 leads to constitutive activation of the PI3K pathway. Activated = PI3K=20 phosphorylates several downstream effectors, including AKT. = Inhibitors of=20 PI3K and AKT have undergone preclinical evaluation with = encouraging=20 results.^92,93=20 Perifosine (Keryx Biopharmaceuticals, New York, NY), an oral AKT = and AMPK=20 inhibitor, is undergoing clinical evaluation in malignant=20 gliomas.⁹³=20 Also, preclinical studies have demonstrated antitumor efficacy of = several=20 integrin-linked kinase inhibitors by AKT inhibition.⁹⁴

mTOR is downstream from AKT and can be activated = by not only=20 AKT but also RAS pathways. Rapamycin (Sirolimus, Rapamune; Wyeth,=20 Collegeville, PA) and its synthesized analogues, temsirolimus = (CCI-779,=20 Wyeth), everolimus (RAD001, Novartis), and AP23573 (Ariad = Pharmaceuticals,=20 Cambridge, MA), have been evaluated in clinical trials of = malignant=20 gliomas. Two recent phase II studies of temsirolimus monotherapy = in=20 recurrent GBMs demonstrated varied radiographic improvement = without=20 survival benefit as measured by a PFS-6 of only = 2.5%=967.8%.^95,96=20 Taken together, rapamycin analogues might not be sufficient for = tumor=20 control as monotherapies. One plausible explanation may be the = selective=20 inhibition of only the mTOR1C complex without affecting mTOR2C = complexes=20 that regulate cell polarity, growth, and invasion.⁹⁷=20 Targeted deletion of entire mTOR activities by small interfering = RNA can=20 rescue the sensitivity of rapamycin-resistant cell lines to=20 rapamycin.⁹⁸=20 Alternatively, blocking mTOR may stimulate other signaling = elements=20 critical for cell survival. Few preclinical studies demonstrated = that=20 inhibition of mTOR can stimulate kinase activity of its immediate = upstream=20 effector, AKT, which may decrease the antitumor = efficacy.⁹⁹=20 PI-103, a novel inhibitor of both PI3K and mTOR, has shown = promising=20 activity in both in vitro and in=20 vivo models of malignant gliomas, partly due to blocking = activated=20 PI3K/AKT induced by mTOR inhibition.¹⁰⁰

=20

=20

Protein Kinase C = Pathways=20

Protein kinase C (PKC) is a serine/threonine = kinase that=20 regulates cell proliferation, invasion, and angiogenesis. The = PKC-β=20 inhibitor with activity against glycogen synthase kinase 3β, = enzastaurin=20 (LY317615; Eli-Lilly, Indianapolis, IN), has demonstrated activity = against=20 glioma xenografts as both monotherapy and synergism with=20 radiotherapy.^101,102=20 A phase II trial of enzastaurin in recurrent malignant gliomas = yielded a=20 promising 29% radiographic response rate.¹⁰³=20 However, a multicentered phase III trial of enzastaurin versus = lomustine=20 was prematurely terminated because of failure to achieve a = survival=20 benefit in an interim analysis.

=20

=20

Miscellaneous

<= /TD>

=

=

<= /TD>

=

Several other molecular targets are candidates for = development of novel therapy in malignant astrocytoma. The src = kinase is a=20 multifunctional, intracellular tyrosine kinase that regulates = cellular=20 proliferation, survival, motility, and angiogenesis.¹⁰⁴=20 Dasatinib (BMS-354825; Bristol-Myers Squibb, New York, NY), a dual = inhibitor of src and bcr-abl kinases, is undergoing clinical = evaluation in=20 malignant glioma as both monotherapy and in combination with = erlotinib.=20 Focal adhesion kinase (FAK) is a tyrosine kinase involved in = cancer=20 invasion and metastasis. These kinases are dynamic intracellular = proteins=20 that link the extracellular matrix to the cell cytoskeleton = through=20 integrins. Higher expression of FAK correlates with glioma grade. = FAK=20 inhibitors have demonstrated preclinical efficacy in malignant=20 gliomas.¹⁰⁵=20 Thus, development of these inhibitors in clinic may be = warranted.

Integrins are cell adhesion molecules important in = glioma=20 cell migration and angiogenesis.¹⁰⁶=20 Cilengitide (EMD121974; EMD Pharmaceuticals, Durham, NC), an = intravenous=20 inhibitor of = α_vβ₃ and=20 α_vβ₅ = integrins,=20 demonstrated preclinical efficacy against malignant glioma. A = phase I=20 trial of cilengitide in recurrent malignant gliomas by the New = Approaches=20 to Brain Tumor Therapy group has been completed with no = dose-limiting=20 toxicities and an encouraging 10% radiographic response = rate.¹⁰⁷=20 Preliminary results of a phase I/II trial of cilengitide with = temozolomide=20 and radiation therapy followed by cilengitide/temozolomide in = newly=20 diagnosed GBM have been encouraging with a PFS-6 of 65%. A phase = II trial=20 of cilengitide in recurrent GBM has also been completed.

Histone deacetylase (HDAC) inhibitors induce cell = cycle=20 arrest and apoptosis in cancer cells.¹⁰⁸=20 Pretreatment with an HDAC inhibitor, suberoylanilide hydroxamic = acid=20 (SAHA, Vorinostat; Aton Pharma, Tarrytown, NY), sensitizes glioma = cells to=20 radiation and chemotherapy.^109,110=20 Clinical trials of vorinostat as monotherapy or in combination = with=20 temozolomide in malignant glioma are ongoing. Another HDAC = inhibitor,=20 depsipeptide (FK228; Gloucester Pharmaceuticals, Cambridge, MA),=20 demonstrated preclinical efficacy in GBM. A phase I/II study of=20 depsipeptide in recurrent malignant gliomas is ongoing by the = North=20 American Brain Tumor Consortium.

The ubiquitin=96proteasome system is important in = regulating=20 cell cycle proteins to balance cell proliferation and=20 apoptosis.¹¹¹=20 Disruption of the temporal degradation of these regulatory = molecules by=20 proteasome inhibitors can induce cell growth arrest and apoptosis. = A=20 proteasome inhibitor, bortezomib (Velcade, PS-341; Millennium=20 Pharmaceuticals, Cambridge, MA), induced cell cycle arrest and = apoptosis=20 in glioma cell lines.¹¹²=20 Several clinical trials of bortezomib in combination with = temozolomide or=20 other targeted agents such as vorinostat, bevacizumab, or = tamoxifen are=20 ongoing¹¹³=20 or planned.

=20

=20

Strategies to Improve Therapeutic=20 Efficacy

<= /TD>

=

=

=

=

Current targeted therapies in malignant gliomas = have been=20 associated with various response rates and modest to no survival = benefits=20 (Table=20 1). Several strategies have been developed to improve the=20 effectiveness of targeted agents for this devastating cancer (Fig.=20 3). Among these may include new target identification, drug = delivery=20 enhancement, multitargeted inhibitors, new treatment combinations, = biomarker identification, and improved preclinical and clinical=20 designs.

=20

TABLE 1. = Molecular Targeted=20 Therapies Disrupting Signal Transduction Pathways in Malignant=20 Gliomas

Target(s)	Agent(s)	Phase	Results/Status
Growth factor=20 receptors
EGFR	Gefitinib	II	Recurrent GBM (1st = relapse): no=20 radiographic response; PFS-6: 17%

Erlotinib (=B1 TMZ)	I/II	Recurrent MG: 14% PR; = PFS-6:=20 11%

Erlotinib	I/II	Recurrent MG: 6%=9625% PR; = PFS-6=20 10%=9620%

Erlotinib + RT	I	Newly diagnosed GBM: = MTD=97not=20 reached; median TTP: 26 weeks

Erlotinib (+TMZ, = bevacizumab)	II	Newly diagnosed = GBM=97stable after=20 radiation therapy: ongoing

Cetuximab	II	Recurrent GBM: = ongoing

Cetuximab (+TMZ/RT)	I/II	Newly diagnosed GBM: = ongoing

Cetuximab=20 (+bevacizumab/irinotecan)	II	Recurrent GBM: = ongoing
VEGF	Bevacizumab + = irinotecan	II	Recurrent MG: 63% CR + = PR PFS-6=20 GBM 43%; AA/AO 61%

Bevacizumab versus = bevacizumab +=20 irinotecan	II	Recurrent GBM: = completed

Bevacizumab + erlotinib = (EGFR=20 inhibitor)	II	Recurrent MG: = ongoing

Bevacizumab + metronomic = TMZ	II	Recurrent MG: = ongoing

Bevacizumab plus = etoposide	II	Recurrent MG: = ongoing

Bevacizumab plus XRT	II	Newly diagnosed GBM: = ongoing

Bevacizumab plus XRT and = TMZ	II	Newly diagnosed GBM: = ongoing

VEGF trap	II	Recurrent MG: = ongoing

Vatalanib (=B1 = temozolomide or=20 lomustine)	I/II	Recurrent GBM: 4% PR; 66% = SD; TTP:=20 12=9616 weeks

Pazopanib = (+lapatinib-HER1/2=20 inhibitor)	I	Recurrent MG: = ongoing

Cediranib (AZD2171)	II	Recurrent GBM: 56% PR; = APF-6:=20 27.6%
HGF/SF	AMG-102	II	Advanced MG: = ongoing
PDGFR	Imatinib = mesylate	II	Recurrent GBM: PFS-6: = 3%

Recurrent AA: PFS-6: = 10%

Imatinib = mesylate +=20 hydroxyurea	II	Recurrent GBM: 9% PR; 42% = SD

PFS-6: 27%

Imatinib mesylate, = hydroxyurea, and=20 vatalanib	I	Recurrent MG: = ongoing
Intracellular=20 effectors
RAS=20 (Farnesyltransferase)	Tipifarnib	I/II	Recurrent GBM: PFS-6: = 12%

Recurrent AA: PFS-6: = 9%

Lonafarnib = (+TMZ)	I	Recurrent GBM: 27% = PR;

PFS-6: 33%
RAF=20 (+VEGFR-2)	Sorafenib (+ erlotinib, = tipifarnib,=20 or temsirolimus)	I/II	Recurrent MG: = ongoing

Sorafenib = (+erlotinib)	II	Recurrent/progressive = GBM
AKT	Perifosine	II	Recurrent MG: = ongoing
mTOR	Sirolimus = (+gefitinib)	I	Recurrent MG: MTD = identified; 6% PR;=20 38% SD

Temsirolimus	I/II	Recurrent GBM: = radiographic=20 response: 5%=9636%; PFS-6: 2.5%=967.8%

Temsirolimus = (+erlotinib)	I/II	Recurrent GBM: = ongoing

Everolimus (+AEE788)	I	Recurrent GBM: = completed
PKC-β	Enzastaurin	II	Recurrent GBM: 22% PR; 5% = SD

Recurrent AA: 24% PR; 13% = SD

Enzastaurin + = carboplatin	I	Recurrent MG: = ongoing

Enzastaurin (+TMZ-RT)	I/II	Newly diagnosed GBM: = ongoing

Enzastaurin versus = lomustine	III	Recurrent MG: discontinued = because=20 of lack of interim survival benefit

Enzastaurin + = bevacizumab	II	Recurrent MG: = ongoing

EGFR, VEGFR	AEE788	I	Recurrent GBM: = completed

Vandetanib (ZD6474)	I/II	Recurrent MG and = progressive=20 low-grade glioma: ongoing
EGFR,=20 HER2/neu	Lapatinib	II	Recurrent GBM: = ongoing

Lapatinib (+pazopanib; = VEGFR=20 inhibitor)	I	Recurrent MG: = ongoing
PDGFR,=20 VEGFR	Sunitinib (SU11248)	I/II	Recurrent GBM: = planned

Sunitinib	II	Brain metastases in lung = cancer:=20 ongoing
FLT-3, PDGFR, = c-KIT	Tandutinib (MLN518)	I/II	Recurrent GBM: = ongoing
Miscellaneous
Integrins	Cilengitide	I	Recurrent MG: MTD=97not = reached; 4%=20 CR; 6% PR; 8% SD

Cilengitide	II	Recurrent GBM: = completed

Cilengitide + TMZ/RT	II	Newly diagnosed GBM: = PFS-6:=20 65%
Src	Dasatinib	II	Recurrent GBM: = ongoing
HDAC	Vorinostat + TMZ	I	Malignant gliomas: = ongoing

Vorinostat	II	Recurrent GBM: completed=20 accrual

Depsipeptide	I/II	Recurrent MG:=20 ongoing

=20

= Figure 3. = Strategies=20 to improve effectiveness of designer drugs. ABCG2, = ATP-binding=20 cassette protein G2; BBB, blood=96brain barrier; BCRP, = breast cancer=20 resistance protein; CED, convection-enhanced = delivery.=20

[Normal View=20 ]

=20

=20

=20

Identification of = New=20 Targets

Several inhibitors of new targets have emerged in=20 preclinical or early clinical development for the treatment of = cancers.=20 Cell cycle regulators such as cyclin-dependent kinase inhibitors,=20 checkpoint kinase inhibitors, aurora kinase¹¹⁴=20 and polo-like kinase inhibitors, and mitotic kinesin inhibitors = have been=20 evaluated in various hematologic and solid malignancies. These = agents may=20 also be candidates for glioma treatment. Preclinical studies in = malignant=20 gliomas have elucidated many other potential targets, which may = include=20 cannabinoid receptors,¹¹⁵=20 telomerase, myc, and signal transducer and activator of = transcription=20 3.¹¹⁶=20 New gene genome analyses such as those found in the National = Cancer=20 Institute, the Cancer Genome Atlas, Genomic = Identification of Significant Targets in Cancer, system biology, = and=20 bioinformatics may identify new therapeutic targets.^117,118

Brain tumors, like all cancers, are essentially = aberrant=20 organ systems with heterogeneous cell types that include not only=20 neoplastic cells but also endothelial cells, inflammatory cells, = and=20 invading astrocytes. The neoplastic compartment displays cells = with a=20 diversity of differentiation markers. More than a century ago, = these=20 observations led to the hypothesis that cancers contain a subset = of=20 relatively undifferentiated cells. In parallel to the function of=20 tissue-specific stem cells in development and regeneration, = neoplastic=20 cells that display a stem cell=96like phenotype may be important = in tumor=20 initiation and maintenance. Thus, cancer stem cells (also called=20 tumor-initiating cells or tumor-propagating cells) have been = defined by=20 sustained self-renewal and the ability to generate the diversity = of tumor=20 cell types present in cancers. These functional assays have = limited the=20 ability to study cancer stem cells prospectively until the recent=20 development of cell surface markers that can be used to enrich or = deplete=20 cancer stem cells. It is essential to the understanding of the = cancer stem=20 cell hypothesis that the presence of cancer stem cells does not = require a=20 stem cell of origin. Recent identification of cancer stem cells in = solid=20 malignancies, including glioblastoma, has generated a change of = thought=20 for cancer research, including the therapeutic = discovery.¹¹⁹=20 Glioblastoma stem cells have contributed to malignant properties,=20 including angiogenesis and therapeutic resistance. Glioblastoma = stem cells=20 promote tumor angiogenesis by secreting VEGF.¹²⁰=20 The effects of glioblastoma stem cells on angiogenesis can be = specifically=20 inhibited by bevacizumab. Brain tumor stem cells reside in a niche = that=20 may also represent a therapeutic target. Recent evidence suggests = that=20 modulation of some bone morphogenic proteins can decrease = tumorigenic=20 potential of glioma cancer stem cells.¹²¹=20 Also, targeting checkpoint kinases (CHK1 and CHK2) with = small-molecule=20 inhibitors can overcome the radioresistance of glioblastoma stem=20 cells.¹²²=20 Targeting cancer stem cells may therefore represent a new = therapeutic=20 approach in glioblastomas.

=20

=20

Drug Delivery and=20 Pharmacokinetics

Although most kinase inhibitors are small, they = may not be=20 able to cross the blood=96brain barrier by their polarity; = hydrophilicity;=20 and active drug efflux transporters at the blood=96brain,=20 blood=96cerebrospinal fluid, and blood=96tumor barriers. Drug = efflux=20 transporters are also present on tumor cells, preventing = intratumoral=20 uptake of therapeutic agents.¹²³=20 Modulation of drug transporters may represent a new potential = strategy to=20 improve efficacy of targeted agents.

CED is an approach to increase locoregional = delivery of=20 therapeutics that has been investigated in malignant=20 astrocytoma.¹²⁴=20 Increased interstitial pressure in brain tumors may limit drug = delivery=20 from systemic vasculature and regular local infusion. CED uses the = pressure gradient concept of continuous high-pressure, = small-volume=20 infusion over long periods (3=965 days) to optimize delivery of = therapeutics=20 in tumor/surgical bed via stereotactically placed catheters. = Various=20 therapeutic agents delivered by CED have been evaluated, including = chemotherapies, gene/virus therapy, and ligand=96toxin conjugates. = Other new=20 delivery approaches may include liposome-conjugated drugs, = genetically=20 modified stem cells, and nanoparticle delivery systems, which all = are=20 under preclinical development.

Pharmacokinetic evaluation is important in all = phase I=20 studies to determine drug level and potential drug=96drug = interactions.=20 Also, some patients with brain tumors are treated with = antiepileptic=20 drugs. Several antiepileptic drugs such as phenytoin, = phenobarbital,=20 carbamazepine, oxcarbazepine, and primidone are hepatic cytochrome = P450=20 inducers, which can increase metabolism and decrease therapeutic = levels of=20 several targeted agents. Therefore, patients should be stratified = into two=20 groups in clinical trials on the basis of their coadministration = of=20 enzyme-inducing antiepileptic drugs (EIAEDs). Dosages between two = arms=20 should be escalated independently and pharmacokinetic studies = should be=20 performed. An alternative approach is to perform an initial phase = I/II=20 trial only in patients not on EIAEDs. If the new agent is found to = be safe=20 and efficacious, it may be further evaluated in patients on=20 EIAEDs.

=20

=20

Multitargeted Inhibitors

First-generation kinase inhibitors, which disrupt = only one=20 or a few targets, have been associated with modest clinical = benefit in=20 unselected glioma patient populations. These failures may result = from=20 genetic heterogeneity and the existence of multiple parallel or=20 compensatory pathways. Therefore, targeting only single kinases or = pathways may not be sufficient for tumor control, unlike the = success seen=20 in chronic myelogenous leukemia and gastrointestinal stromal tumor = treated=20 with imatinib mesylate monotherapy.^125,126=20 These two cancers exhibited "oncogene or pathway addiction" (i.e., = bcr-abl=20 for chronic myelogenous leukemia and c-kit for gastrointestinal = stromal=20 tumor), which served as targets for imatinib = mesylate.¹²⁷=20 Recent evidence has demonstrated concomitant activation of several = receptor tyrosine kinases in glioma cell lines, xenografts, and = primary=20 glial tumors.¹²⁸=20 Simultaneous disruption of multiple kinases is more effective than = inhibition of one kinase in decreasing downstream signaling, cell=20 survival, and anchorage-independent growth. Currently, there are = many=20 multitargeted kinase inhibitors targeting multiple signal = transduction=20 pathways. AEE788 (Novartis) is a dual EGFR and VEGFR-2 inhibitor = with=20 in vitro and in vivo = efficacy=20 against glioblastoma.¹²⁹=20 A multicentered clinical study of AEE788 monotherapy in malignant = gliomas=20 has been completed. Vandetanib (ZD6474, Zactima; AstraZeneca), = another=20 inhibitor of EGFR/VEGFR-2, demonstrated cooperative effect with = radiation=20 and prolonged survival in murine models of intracranial glioma=20 xenografts.¹³⁰=20 A phase I/II trial of vandetanib in malignant gliomas is ongoing.=20 Sunitinib malate (Sutent, SU11248; Pfizer), an inhibitor of = VEGFR-2,=20 PDGFR, c-KIT, and FMS-like tyrosine kinase (FLT) 3, has antitumor = activity=20 against subcutaneous malignant glioma xenografts.¹³¹=20 A phase II study of sunitinib malate in malignant gliomas is = ongoing.=20 Tandutinib (MLN518, CT53518; Millennium Pharmaceuticals) is a new = c-KIT=20 and FLT-3 inhibitor that demonstrated efficacy in hematologic=20 malignancies.¹³²=20 A phase I/II trial of tandutinib in recurrent GBMs is ongoing. = Clinical=20 development of other multitargeted agents in malignant gliomas is = in=20 progress.

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Combination and = Multimodality=20 Treatments

In addition to multitargeted inhibitors, = combination therapy=20 using agents that target different signaling pathways may = circumvent tumor=20 resistance to single-targeted inhibitors.¹³³=20 Strategy to determine the most promising combinations is important = because=20 the number of therapeutic combinations is almost = limitless.¹³⁴=20 Currently, several strategies can be used to select targeted = agents for=20 combination therapy. Agents targeting the same pathway(s) may be = combined=20 to more potently block the activation of the pathway. For = instance, a=20 combination of cetuximab, a monoclonal antibody to EGFR, and = gefitinib or=20 erlotinib, an EGFR tyrosine kinase inhibitor, offers combinatorial = antitumor benefit in a head and neck cancer model.¹³⁵=20 Clinical trials that disrupt two targets in the same pathway in = malignant=20 gliomas may include a phase I/II trial of sorafenib with erlotinib = or=20 tipifarnib. Cancer cells may compensate for the effects of = specific=20 molecular inhibitors (e.g., rapamycin) through the activation of = feedback=20 loops upstream from the primary target, suggesting that dual = targeting=20 upstream and downstream in a pathway may offer benefit. Clinical = trials=20 have been initiated based on this premise.

The second target can be a different but = tumor-relevant cell=20 type such as targeting endothelial cells in addition to tumor = cells. A=20 preclinical study demonstrated that combination of DC101 (VEGFR-2=20 antibody) and C225 (cetuximab [Erbitux]) improved tumor control by = inhibiting DC101-induced tumor cell migratory effect and vascular=20 co-option.¹³⁶=20 Examples of clinical trials based on this concept may include a = phase I=20 trial of cetuximab, bevacizumab, and irinotecan; phase II trials = of=20 bevacizumab plus erlotinib or sorafenib or enzastaurin; and a = phase I=20 study of lapatinib plus pazopanib in recurrent malignant = glioma.

The second target can be a parallel or = compensatory pathway=20 that may result in the resistance to the first agent. Because = activation=20 of the EGFR and/or PI3K pathway (by loss of PTEN) represents one = of the=20 most common genetic aberrations in GBM, several combination = studies have=20 focused on targeting EGFR and mTOR, downstream intracellular = effectors in=20 the PI3K pathway. Also, malignant gliomas that are resistant to = EGFR=20 inhibitors have demonstrated activation of the PI3K pathway = through IGF-1R=20 activation.⁷¹=20 Therefore, targeting both EGFR and PI3K pathways may overcome the=20 resistance and increase antitumor efficacy. A preclinical study of = AEE788,=20 a dual EGFR and VEGFR-2 inhibitor, and RAD001, an mTOR inhibitor,=20 demonstrated in vitro and in=20 vivo combinatorial benefits. Another study revealed greater = antiproliferative and proapoptotic effects of EKI-785, an EGFR = inhibitor,=20 and rapamycin, than either agent alone in glioma cell = lines.¹³⁷=20 Also, mTOR inhibition enhances sensitivity of GBM cells to EGFR = kinase=20 inhibitors, regardless of their PTEN status.¹³⁸=20 More recently, a combination of erlotinib and PI-103 (dual = PI3K/mTOR=20 inhibitor) has demonstrated superior efficacy in PTEN-mutant = glioma to=20 either monotherapy or therapy combining erlotinib with either PI3K = inhibitor or mTOR inhibitor.¹³⁹=20 The concept of combining EGFR and mTOR inhibitors has translated = into=20 clinical trials such as erlotinib plus temsirolimus, gefitinib or=20 erlotinib plus sirolimus, and AEE788 plus RAD001.^140,141=20 A phase I trial of gefitinib plus sirolimus in recurrent malignant = gliomas=20 demonstrated safety and tolerability with encouraging antitumor=20 activity.¹⁴⁰=20 In addition to EGFR inhibitors, an mTOR inhibitor, RAD001, has = recently=20 been combined with imatinib mesylate (PDGFR inhibitor) and = hydroxyurea in=20 a phase I trial for malignant glioma.

Preclinical studies have demonstrated = combinatorial=20 antiglioma benefit of combining VEGFR and PDGFR kinase inhibitors. = A=20 clinical study of imatinib mesylate/hydroxyurea and vatalanib in = recurrent=20 malignant glioma is ongoing.¹⁴²=20 Furthermore, a clinical trial of imatinib mesylate/hydroxyurea in=20 combination with vandetanib (EGFR/VEGFR inhibitor) in recurrent = malignant=20 glioma has recently been initiated.

Combinations of targeted agents that inhibit = intracellular=20 effectors in downstream parallel pathways have also been = developed.=20 Targeting the PI3K/AKT pathway through antisense oligonucleotides = to=20 integrin-linked kinase offered synergistic antitumor effects with=20 small-molecule RAF-1 or MEK inhibitors.¹⁴³=20 Also, a new RAF inhibitor, LBT613 (Novartis), and everolimus offer = combinatorial benefits in blocking proliferation and invasion of = glioma=20 cell lines.¹⁴⁴=20 On the basis of this rationale, phase I/II trials of sorafenib and = temsirolimus (mTOR inhibitor) are in progress. Several other = promising=20 combinations of targeted agents have undergone preclinical = evaluation. A=20 combination of sorafenib and a PKC-δ inhibitor, rottlerin, or = a proteasome=20 inhibitor, bortezomib, exhibited synergy in apoptosis induction of = glioma=20 cell lines.^145,146=20 A combination of PI3K inhibitor, LY294002, and a chaperone protein = heat=20 shock protein 90 inhibitor, 17-AAG, demonstrated a combinatorial=20 antiproliferative effect in glioma cell lines.¹⁴⁷=20 Clinical development of these combinations may be warranted.

Combinations of targeted agents with = chemotherapies have=20 been evaluated in malignant gliomas.¹⁴⁸=20 One of the most promising combinations is bevacizumab, an = anti-VEGF=20 antibody, plus irinotecan, a topoisomerase I inhibitor. Other=20 chemotherapies currently under clinical investigation with = bevacizumab=20 include temozolomide and etoposide.

Radiation therapy has been a standard of care for = malignant=20 glioma. However, most patients eventually develop recurrence or=20 progression after the treatment. Agents that can enhance or = restore=20 sensitivity of brain tumors to radiation therapy may improve = patient=20 outcome. Preclinical evidence demonstrated that radiation = sensitivity may=20 be regulated by growth factor signaling, DNA damage response = protein=20 activation, and apoptosis-related proteins. Among growth factor = signaling=20 pathways, EGFR was among the first that has been shown to = contribute to=20 radioresistance.¹⁴⁹=20 Clinical trials of gefitinib or erlotinib and radiation therapy = (both=20 conventional and stereotactic radiosurgery) are = ongoing.¹⁵⁰=20 Other pathways such as PDGF, VEGF, and mTOR have also shown = efficacy in=20 enhancing radiation cytotoxicities through different=20 mechanisms.^151=96153=20 The sequence and timing of drug administration in relation to = radiation=20 therapy is crucial because there is a significant difference in=20 combinatorial effects in an animal study.¹⁵⁴

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Identification of=20 Biomarkers

Because only some patients who receive targeted = agents have=20 treatment benefit, identification of predictive biomarkers of = response or=20 resistance is a critical step to select the treatment for each = cancer=20 patient.¹⁵⁵=20 Also, biomarkers may serve as a pharmacodynamic measure to help = monitor=20 in vivo drug effect. In a recent phase I = study of=20 neoadjuvant rapamycin in patients with PTEN-deficient GBM, = inhibition of=20 mTOR activity as measured by reduced p70S6 kinase correlated with=20 decreased tumor cell proliferation as measured by Ki-67=20 staining.¹⁵⁶=20 Biomarkers can help define the optimal biological dose for each = targeted=20 agent because the traditional maximal tolerated dose may not be = the=20 optimal dose for targeted agents to elicit antitumor effect.

Several recent studies using immunohistochemical = analysis of=20 archival tumor specimens have elucidated the molecular = determinants for=20 response to EGFR, VEGF, and mTOR inhibitors in malignant gliomas. = These=20 studies indicate technical feasibility of tumor = immunohistochemistry for=20 biomarker identification in malignant gliomas, which may serve as = a=20 paradigm of biomarker-guided targeted therapy if independently = validated=20 in larger prospective trials.

In addition to tissue biomarkers, other techniques = may also=20 serve as surrogates for response or resistance to therapy, = possibly=20 including circulatory markers and imaging biomarkers. Gene = expression=20 profiling has recently been used to predict response to = chemotherapy or=20 targeted agents in lung cancer.¹⁵⁷=20 This integrated genomic advance may serve as a foundation for = personalized=20 medicine for patients with cancers, including malignant=20 glioma.

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Improved = Preclinical=20 Models

Currently, there are several preclinical models = for=20 evaluating new therapeutic agents in gliomas. Because malignant = gliomas=20 are genetically heterogeneous, even within one patient, using = glioma cell=20 lines with a restricted set of genetic abnormalities for drug = evaluation=20 may not be fully representative of actual human disease. = Heterotopic and=20 orthotopic xenograft systems are traditional models for = preclinical=20 testing of new drugs.¹⁵⁸=20 However, these models may fail to recapitulate the complex tumor=20 microenvironment found in human tumors. Several new animal models = have=20 been developed to overcome this challenge. These models may = include=20 genetically engineered mouse models,¹⁵⁹=20 serially transplanted human xenograft models,¹⁶⁰=20 and cancer stem cell models.¹⁶¹=20 Each animal model has advantages and disadvantages, and some = models face=20 technical challenges. It remains to be elucidated which animal = model=20 serves best for screening of new therapeutics because no model has = been=20 systematically evaluated for predictive ability in clinical=20 trials.

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New Clinical Trial = Designs

Because the number of targeted agents in = development is=20 rapidly increasing, selecting key candidates for clinical = evaluation has=20 recently become a challenge because of the limited number of = glioma=20 patients. New clinical trial designs have been developed to = simultaneously=20 evaluate several agents in a few patients in a timely fashion. = Among these=20 may include adaptive randomization and factorial designs. Adaptive = randomization allows the simultaneous evaluation of several drugs = in=20 multiple treatment arms (testing each arm against the others). = Interim=20 outcome analysis is performed during accrual to adjust the = randomization=20 to enroll more patients into the arm with higher response rate. = This=20 design terminates ineffective agent(s) early in a trial while = optimizing=20 the number of patients in the most promising arm to achieve = primary=20 outcome analysis. Factorial design allows simultaneous evaluation = of=20 several therapeutic combinations with fixed and smaller accrual = numbers of=20 each arm.¹⁶²

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=20

Conclusion

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