ISSN 1693 - 2005 DIGMAnti angiogenesis : a new approach for cancer treatment Abraham Simatupang Department of Pharmacology Faculty of Medicine, indonesian Christian University Jakerta, Indonesia ABSTRACT Angiogenesis, an important physiological factor for developing new vascular bed, has been predicted also as one of the ‘rucial factors of cancer development and metastasis. Angiogenesis is a process controlted by certain chernical substances produced in the body and it is fundamental for reproduction, developmemt, and repair. Groups of endogenous substances, tealfed angiogenesis promoters, such as Vascular Endothelial Growth Factor (VEGF), Fibroblast Growth Factor (FGF) and angiogenesis inhibitors, such as thrombospendin, angiastatin, and endostatin have been characterized. These substances playa major role for balancing the physfological process of angiogenesis. However, angiogenesis is also central ta the growth of cancer. Without blood vessels, cells are unable to grow into tumors. For tumor to develop a metastatic or a lethal phenotype, it must first recruit and sustain its own private blood supply. Tumors unable to induce angiogenesis remain dormant at a microscopic in itu size. ‘Apart of endogenous angiogenesis inhibitors, some synthetic recombinant or other biomolecular generated substances are invented and explored. At least three general categories of angiogenesis inhibitors have been reported to date: (1) synthetic inhibitors, peptides, or antibodies designed to interfere with various steps in the angiogenic process; inhibitors of metalloproteinases, or inhibitors of VEGF and other angiogenic promoters; (2) low molecular weight compounds e.g. TNP-470,53, angiostatic steroids; and (3) endogenous proteins e.g. interferon-alpha, interleukin. Moreover, thalidomide an anti inflammatory agent, once a “culprit” for causing teratogenic effects in the late 50s, is being scrutiny studied for its promising antiangiogenesis effect. This article discusses the pharmaco-biochemistry backgrounds of some anti angiogenesis substances which are currently under intense pre-and clinicaltrials.. Keywords: angiogenesis, VEGF, cancertreatment, FGF ANGIOGENESIS Angiogenesis, or formation of new blood vessels out of pre-existing capillaries is a basic pathophysiologic processes for reproduction, development, and restoration.'Physiological angiogenesis can also be rapidly shortened, indicating that the process is held in confirm physiologically and yet can be activated in response to the proper stimuli, somewhat analogous to the clotting cascade.‘ Numerous endogenous substances that act as inhibitor or promoter of angiogenesis has been invented and through this, the researchers are looking for the benefits of the substances in clinical settings (see Table. 1) Table 1. Endogenous Promoters and Inhibitors of Angiogenesis (Hayes, 1999)* Promoters Inhibitors 1. Fibroblast growth factors 1. Thrombospondin 2. Vascular endothelial 2. Angiostatin growth factor (VEGFY 3. Angiogenin 3. Endostatin 4, Transforming growth 4, Interferonens.y factora 5. Pleiotrophin 5. 16 kDa prolactin fragment 6. Scatter factor 6. Plateletfactor 4 7. Thrombin 7. Angiopoietin 2 8. Angiopoietin 1 Induction of angiogenesis by tumors For more than 100 years, tumors had been observed to be more vascular than normal tissue.” Vasodilatation and hyperemia were observed during surgery and three reports suggested that these phenomena could be related to new blood vessels growth.® A tumor induces this proliferative vascular response from host vessels by changing the balance of positive and negative regulators locally. This “angiogenic switch’ is essential for tumor growth and, may be rate limiting. Convincing evidence exists that, tumors undergo a switch to an angiogenic character as they progress. In cervical carcinoma the development of vascularity can be associated with progression from a non-invasive premalignant stage to invasive carcinoma, The density of micro vessels in tumors is a powerful independent prognostic indicator of distant metastasis and survival, suggesting that tumor vascularisation correlates with growth and metastatic potential, Tumor invasion and metastases The process of metastases is also angiogenesis dependent. Firstly, tumor cells must gain access to the vasculature in the primary tumor, survive the circulation, anchor in the microvasculature of the target organ, depart form this vasculature, grow in the target organ, and induce angiogenesis." This complex processis summarized in Table 2.@ Abraham simatupang Table 2, Tumor-Host Interactions During the Metastatic Cascade (Liotta & Kohn, 2000)" 1Tumorinitiation Carcinagenicinsult, ancogane activation or depression, chromosome rearrangement Karyotypic, genetic, and epigenetic instability, gene amplification, promotion- associated genesand growth factors, mutation or loss of Suppressor gene products Autocrine growth factors or their receptors, receptors for ‘mosthormones, suchas estrogen Multiple angiogenesis factors,including known growth factors Sertum chemoattractants, autocrine motility factors, 2, Promotion nd progression .Uncontrolled proliferation 4.Angiogenesis S.Invasion of localtissues, ‘blood, and lymphatic vessels attachmentreceptors, degradative enzymes, loss of expression of proteinese inhibitors 6 Circulating tumor cell ‘Tumor cell homotypic or arrestand extravasation a, adherenceto endothelium heterotypic aggression Tumor eell interaction with ‘fibrin, platelets, and clotting factors, adhesions to RGD- typereceptors Plateletfactors, tumor cell factors Receptors or laminin, ‘thrombospondin and type lV collagen Metalloproteinases, serine b. retraction of endothelium ¢. adhesionto basement ‘membrane d, dissolution of basement membrane proteinases, herapinase, cathepsin locomotion Autocrine motility factors, chemotaxisfactors, 7.Colony formationat secondary site Receptors ferlocal tissue ‘growth facters, angiogenesis factors, mutation, or loss of, metastasis suppressor genes Resistanceto kiling by host macrophage, natural killer cells, and activated T cells; failure to express, or blocking of, tumor-specific antigens; amplification of drug- resistant gene 8.Evasion of host defenses ‘and resistance to therapy Figure 1 depicts the schematic process of angiogenesis in tumor growth, invasion and metastasis. When the tumor grows beyond 2-3 mm? 'hypoxia causes the tumor cells to over-express and release growth factors (VEGF, Angiogenin) that stimulates the proliferation, migration and differentiation of endothelial cells. This leads to the formation of new blood vessels increasing tumor blood flow, which accelerates tumor growth and invasion to the neighboring tissues. * DIGM Medical Journal Tagogenin = 1 =a, ta scion] cron I as \ era ase tom oy “ten igure 1. Schematic process of angiogenesis tumor growth, invasion and metastasis (Gonzales, 2001)" EPAS-1 (Endothelial Por-ARNT-Sim protein 1), VEGF (Vascular endothelial grawth factor), VEGF- (Vascular Endothelial Growth Factor receptor), HIF (Hypoxia-inducible Factor). PFS (Periceliular Fibrinolytic System), MMP (Matrix metalloproteinases}, ECM (Extra collular matrix), bFGF tbasic Fibroblast Growth Factor Vascular Endothelial Growth Factor (VEGF) VEGF is the most potent angiogenic cytokine and it acts as an endothelial cell-specific mitogen."""* VEGF has at least 4 classes namely VEGF A, B, C, and D, and they belong to the VEGF/PDGF super family. The two VEGF-specific tyrosine kinase receptors, VEGFR-1 (Fit-1) and VEGFR-2 (KDR/Flk-1), are expressed on vascular endothelium, and to lesser ‘extent on monocytes/macrophages and certain tumor cell types.’ The most critical requirement for its biologic response is an interaction of VEGF with VEGFR-2. The main effect of VEGF is to induce the permeability for fibrin to provide a functional matrix for endothelial cells. Thus, endothelial cells become activated, proliferate and migrate.’ Researchers have been focusing to discover the antibody of VEGF ar an antagonist to VEGFR-2, such as anti-VEGF monoclonal antibody and SU5416, respectively." Matrix Metalloproteinases (MMP) ‘Angiogenesis is an invasive process that requires proteolysis of the extracellular matrix, and proliferation and migration of the endothelial cells, as well as synthesis of new matrix component.2? MMP are a family of neutral metalloenzymes secreted as latent proenzymes. They require activation through proteolytic cleavage of the amino terminal domain. ‘Their activity should be activated by Zné+ and Ca*+."* 2122 Moreover, MMPS are inhibited by members of the endogenous tissue inhibitor of metalloproteinase (TIMP). The balance between matrix degradation and formation is determined by the levels of activated MT- MMPs, MMPs, and free TIMP'* New substances that interfere the activation of MMPs have been characterized and are being investigated in pre- and clinical trials, such as Marismastat*"*