Cancer Therapy: Clinical A Vasculature-Targeting Regimen of Preoperative Docetaxel with or without Bevacizumab for Locally Advanced Breast Cancer: Impact on Angiogenic Biomarkers

Purpose: Taxanes have effects on angiogenesis causing difficulties in separating biological effects of chemotherapy from those due to angiogenesis inhibitors. This randomized phase II trial was designed to evaluate the additional biomarker effect on angiogenesis when bevacizumab is added to docetaxel. Experimental Design: Patients with inoperable breast cancer were randomized to either 2 cycles of preoperative docetaxel (D) 35 mg/m i.v. weekly for 6 weeks, followed by a 2-week break; or docetaxel with bevacizumab 10 mg/kg i.v. every other week for a total of 16 weeks (DB). Plasma and serummarkers of endothelial damage, dynamic contrastenhanced magnetic resonance imaging (DCE-MRI), and tumor microvessel density were assessed before treatment and at the end of each preoperative cycle. Results: Forty-nine patients were randomized (DB, 24; D, 25). There was no difference in overall clinical response, progression-free survival, or overall survival. Vascular endothelial growth factor increased during treatment; more so with DB (P < 0.0001). Vascular cell adhesion molecule-1 (VCAM-1) also increased (P < 0.0001); more so with DB (P = 0.069). Intercellular adhesionmolecule increased (P = 0.018) and E-selectin decreased (P = 0.006) overall. Baseline levels of VCAM-1 and E-selectin correlatedwith clinical responseby univariate analysis. DCE-MRI showed a greater decrease in tumor perfusion calculated by initial area under the curve for the first 90 seconds inDB (P = 0.024). DCE-MRI also showed an overall decrease in tumor volume (P = 0.012). Conclusion: Bevacizumab plus docetaxel caused a greater increase in vascular endothelial growth factor and VCAM-1, and a greater reduction in tumor perfusion by DCE-MRI compared with docetaxel. Clinical outcomes of inoperable breast cancer were predicted by changes in VCAM-1 and E-selectin. Numerous studies have shown that therapeutic disruption of nascent vasculature is effective in mediating tumor regression (1). A primary target for antiangiogenic therapy is vascular endothelial growth factor (VEGF), a potent and specific regulator of tumor angiogenesis and endothelial cell survival (2–8). VEGF also induces vascular permeability, which is a critical step in promoting tumor growth, and induces the expression of adhesion molecules such as vascular cell adhesion molecule-1 (VCAM-1) and intracellular adhesion molecule-1 (ICAM-1) on endothelial cells (9–11). VCAM-1 is a type-1 transmembrane glycoprotein important for cell adhesion needed for metastasis and is expressed on endothelial cells in response to VEGF stimulation or inflammation (12). VCAM-1 is also present in a soluble form and may function as attractants for endothelial cells (13). Similar to VCAM-1, ICAM-1 is a member of the immunoglobulin-like adhesion molecules and high circulating levels have been associated with a greater propensity Authors' Affiliations: Developmental Therapeutics Program and Translational Research Shared Resource, Case Comprehensive Cancer Center, Departments of Medicine, Radiation Oncology, Biostatistics and Epidemiology, Pathology, Radiology, and Surgery, University Hospitals Case Medical Center, Cleveland, Ohio; Dana-Farber Cancer Institute, Boston, Massachusetts; National Cancer Institute, Bethesda, Maryland; and Mary Babb Randolph Cancer Center, West Virginia University School of Medicine, Morgantown, West Virginia Received 11/12/08; revised 12/31/08; accepted 1/24/09; published OnlineFirst 5/5/09. Grant support: NIH grants: K23 CA87725 (B. Overmoyer); P30 CA43703, Avon Supplement to P30 C143703 (B. Overmoyer), U01 CA62502 and National Cancer Institute Translational Research Initiative; M01 RR00080; Sanofi Aventis. The costs of publication of this article were defrayed in part by the payment of page charges. This articlemust therefore beherebymarkedadvertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Requests for reprints: Beth Overmoyer, Dana-Farber Cancer Institute, Boston, MA 02115. E-mail: [email protected]. F 2009 American Association for Cancer Research. doi:10.1158/1078-0432.CCR-08-2917 3583 Clin Cancer Res 2009;15(10) May 15, 2009 www.aacrjournals.org Research. on July 15, 2017. © 2009 American Association for Cancer clincancerres.aacrjournals.org Downloaded from for metastatic dissemination (14, 15). E-selectin is expressed on endothelial membranes as well as secreted, is up-regulated by inflammation, and is associated with the development of metastasis (16). In addition, fluctuations in E-selectin levels may be a more specific marker of breast cancer than other malignancies (17). Expression of these endothelial adhesion molecules seem to correspond with clinical disease status and, thus, can be investigated as a surrogate marker for disease response (18, 19). Bevacizumab (rhuMAbVEGF, Avastin; Genentech) is a humanized monoclonal antibody with binding specificity for VEGF. Clinical trials investigating the effect of this antibody with or without chemotherapy in the treatment of locally advanced or metastatic breast cancer have been reported with modest clinical results (20-24). This supports the need to document the direct biological consequence of bevacizumab therapy on breast cancer in vivo to differentiate its effects from that of chemotherapy. Wedam et al. (22) examined tumor biopsy specimens in 21 patients with inflammatory and locally advanced breast cancer treated with bevacizumab. An analysis of breast cancer tissue sampled pretherapy and posttherapy revealed a median decrease of 66.7% in phosphorylated VEGFR2 (P = 0.004) and a median increase of 128.9% in tumor apoptosis (P = 0.0008). There were no significant changes in microvessel density or VEGF-A expression. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameters reflected significantly reduced tumor blood perfusion after bevacizumab administration. A single-arm study of combination bevacizumab and docetaxel in metastatic breast cancer revealed a significant association between the cell adhesion molecule, E-selectin, and clinical response (23). There is evidence to suggest that docetaxel administered on a weekly basis has potent antiangiogenic effects in addition to its cytotoxic antitumor activity (25, 26). These antiangiogenic effects of docetaxel increase synergistically with the addition of bevacizumab (27). These findings raise the question of the added benefit of bevacizumab to the antiangiogenic effects of docetaxel in the treatment of breast cancer. In an attempt to target tumor vasculature anddifferentiate the antiangiogenic behavior of chemotherapy from that of a targeted antiangiogenesis inhibitor, we designed a phase II randomized trial of weekly docetaxel versus weekly docetaxel combined with bevacizumab in patients with inoperable breast cancer. We hypothesized that the patients receiving combination therapy with docetaxel and bevacizumab would experience a greater effect on angiogenesis exhibited by a greater reduction in tumor microvascular density, more significant alterations in circulating markers of endothelial adhesion, and a larger decrease in tumor perfusion as measured by DCE-MRI than those receiving docetaxel alone. Patients and Methods Patients. Men and women age ≥18 y were eligible if they had newly diagnosed, histologically confirmed, inoperable adenocarcinoma of the breast as confirmed by consensus decision of the multidisciplinary Case Comprehensive Cancer Center Tumor Board. Those with stage IV breast cancer were eligible if they presented with a concurrent locally advanced breast cancer. No prior treatment for breast cancer was allowed and measurable disease was required. Other eligibility criteria included the following: Eastern Cooperative Oncology Group performance status of <2, normal organ and bone marrow function as described elsewhere (28), and a calculated left ventricular ejection fraction of >45%. Patients were excluded from participation if they had New York Heart Association classification III or IV heart disease, central nervous system metastases, major surgery within 28 d of the start of therapy, or a history of thromboses. Full-dose anticoagulation was not permitted. Informed consent was obtained before the patient undergoing any investigational procedure. In 2005, bevacizumab was found to be of therapeutic benefit for metastatic breast cancer (24), and trastuzumab was determined to be efficacious in the treatment of adjuvant disease (29). These findings changed practice patterns and limited subsequent trial accrual, resulting in early study termination after enrollment of 49 of 60 planned