REVIEW ARTICLE

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Epidermal Growth Factor Receptor Tyrosine Kinase as a Target for Anticancer Therapy
Eric Raymond, Sandrine Faivre and Jean Pierre Armand
Department of Medicine, Institute Gustave-Roussy, Villejuif, France

Abstract

Increasing knowledge of the structure and function of the epidermal growth factor receptor (EGFR) subfamily of tyrosine kinases and of their role in the initiation and progression of various cancers has, in recent years, provided the impetus for a substantial research effort aimed at developing new anticancer therapies that target specific components of the EGFR signal transduction pathway. Selective compounds have been developed that target either the extracellular ligand-binding region of the EGFR or the intracellular tyrosine kinase region, resulting in interference with the signalling pathways that modulate mitogenic and other cancer-promoting responses (e.g. cell motility, cell adhesion, invasion and angiogenesis). Potential new anticancer agents that target the extracellular ligand-binding region of the receptor include a number of monoclonal antibodies, immunotoxins and ligand-binding cytotoxic agents. Agents that target the intracellular tyrosine kinase region include small molecule tyrosine kinase inhibitors (TKIs), which act by interfering with ATP binding to the receptor, and various other compounds that act at substrate-binding regions or downstream components of the signalling pathway. Currently, the most advanced of the newer therapies undergoing clinical development are antireceptor monoclonal antibodies (e.g. trastuzumab and cetuximab) and a number of small molecule EGFR-TKIs principally of the quinazoline and pyrazolo-pyrrolo-pyridopyrimidine inhibitor structural classes. The latter group of compounds offers several advantages in cancer chemotherapy, including the possibility of inhibiting specific deregulated pathways in cancer cells while having minimal effects on normal cell function. They also have favourable pharmacokinetic and pharmacodynamic properties and low toxicity, and some TKIs such as the reversible inhibitor ZD1839 (Iressa)1,2 are now undergoing phase II to III clinical trials. In addition, the accumulation of evidence from laboratory studies strongly suggests that EGFR-selective TKIs will have synergistic effects with other antitumour agents or therapy such as cytostatic agents, conventional cytotoxic drugs and radiotherapy. As our knowledge of signal transduction pathways in cancer increases, it is hoped that further advances in this area will allow the therapeutic potential of these compounds as anticancer agents to be realised.
1 Iressa is a trade mark of the AstraZeneca group of companies. 2 Use of a trade name is for product identification purposes only, and does not imply endorsement.

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Tyrosine kinases are proteins involved in both normal cell growth and malignant transformation, and were discovered more than 20 years ago. Numerous different families of tyrosine kinases have been identified, many of which are integral to transmembrane receptors that act to transduce extracellular signals to intracellular responses, while others are intracellular and are referred to as nonreceptor tyrosine kinases.[1] The involvement of tyrosine kinases in the genesis of cancer became evident from the discovery that increased tyrosine kinase activity is a hallmark of neoplastic cells, and the degree of tyrosine kinase activity has been shown to correlate with the degree of malignant transformation. Indeed, substantial evidence now exists to implicate abnormal signal transduction from tyrosine kinases in the initiation, growth and metastases of many human tumours.[1] Among the best studied of the receptor tyrosine kinases is the epidermal growth factor receptor (EGFR) subfamily, in particular those encoded by the proto-oncogenes c-erbB-1/HER-1/EGFR (commonly referred to as EGFR) and c-erbB-2/HER2/neu (commonly referred to as HER-2). The evidence implicating a direct link between the EGFR subfamily of tyrosine kinases and human cancers is currently the most convincing.[1] Studies of various tumours have revealed that many express either EGFR or one of its common ligands, epidermal growth factor (EGF) and transforming growth factor- (TGF), and some express both the receptor and one of the ligands (table I).[2,3] This review focuses on the EGFR subfamily and its role in tumourigenesis. It also provides a brief summary of the various approaches that have been investigated to inhibit tyrosine kinase activity via targeting of this receptor subfamily, as part of the development of new anticancer therapies. 1. EGFR Structure and Function EGFR is a 170 kDa transmembrane glycoprotein that has ligand-dependent intracellular tyrosine kinase activity. It is present in most cell types, though not haematopoietic cells.[4] As depicted in figure 1, the EGFR is composed of 3 major regions:
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Table I. Epidermal growth factor receptor (EGFR) expression in human carcinomas Tumor types Non-small cell lung cancer EGFR expression TGF expression EGF expression EGFR overexpression: all patients squamous cell carcinoma non-squamous cell carcinoma Colorectal Gastric (advanced) Pancreatic Ovarian Breast Prostate 45-70 57-92 36-58 25-77 33 30-50 35-70 15-30 40 Frequency of expression (%) 40-80 81-93 86-99 0

EGF = epidermal growth factor; TGF = transforming growth factor-.

an N-terminus extracellular region, a hydrophobic transmembrane region, and a C-terminus intracellular region which contains the tyrosine kinase domain. The extracellular region is a ligand-binding site for various polypeptide growth factors, predominantly EGF and TGF.[4,5] The integrated biological responses to EGFR signalling are pleiotropic and include mitogenesis or apoptosis, enhanced cell motility, protein secretion, and differentiation or dedifferentiation. In addition to being implicated in morphogenesis, maintenance and repair, upregulated EGFR signalling has been associated with a wide variety of tumours that progress to invasion and metastasis.[6]
1.1 Ligands

EGFR is the only known receptor for EGF and TGF, but it is not specific for these ligands, as others such as amphiregulin, betacellulin, heparinbinding EGF (HB-EGF), epiregulin, and vaccinia virus growth factor (VGF) also bind to EGFR.[7-9] The most widely expressed ligand in human tissues is TGF. Both TGF and EGF exert mitogenic activity and are generated by extracellular proteolytic cleavage of transmembrane precursors, though at different sites. TGF is produced by both normal
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Extracellular ligand-binding region (glycosylated amino terminus)

Hydrophobic transmembrane region

Cytoplasmic region

C terminus: tyrosine residues 1068, 1086, 1148, 1173 (phosphorylation sites)

Ligand (e.g. EGF, TGF)

Tyrosine kinase domain ATP Substrate tyrosine phosphorylation

Signal transduction

Nucleus

Ligand binding causes receptor dimerisation which enables transphosphorylation to occur between two receptors

Cell membrane

Lysine residue 721 (necessary for ATP binding)

Fig. 1. Schematic representation of the structure of epidermal growth factor receptor (EGFR) and its function. The 3 major regions are as follows: (i) the glycosylated N-terminus extracellular region (621 amino acids); (ii) the hydrophobic transmembrane region (23 amino acids); and (iii) the C-terminus cytoplasmic region (542 amino acids), which contains the tyrosine kinase domain (approximately 250 amino acids). The lysine residue 721 within this domain binds to ATP, generating phosphate for the tyrosine phosphorylation reaction. The major sites of phosphorylation are located at the C terminus (i.e. tyrosine residues 1068, 1086, 1148 and 1173). Stimulation of EGFR tyrosine kinase following binding of a ligand [e.g. transforming growth factor- (TGF) or epidermal growth factor (EGF)] to a receptor leads to its transphosphorylation and to phosphorylation of tyrosine residues from various cellular substrates. As a consequence, signalling pathways are activated such that extracellular signals are transduced to intracellular responses.[3-5]

cells as well as by certain malignant cells, and acts locally via a paracrine, autocrine or juxtacrine mode. EGF is found in almost all body fluids under normal physiological conditions; it is synthesised in the kidney and salivary glands, and seems to function principally via an endocrine mode. In addition to mitogenic activity, TGF and EGF also possess other activities, such as stimulation of arachidonate metabolism, induction of bone resorption and hypercalcaemia, constrictor activity on vascular smooth muscle, and inhibition of gastric acid secretion.[4] Several lines of evidence have implicated the EGFR ligands in having a direct role in tumour development and progression. Both TGF and EGF are believed to induce angiogenesis. EGFR ligands also produce stromal proliferation, extracellular matrix deposition, and induction of cytokine release, and these effects may also influence the local environment of tumours.[9]
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1.2 EGFR and Signal Transduction

On binding of TGF and EGF to the extracellular ligand-binding site of the EGFR, receptor dimerisation occurs and the intracellular tyrosine kinase region is activated, resulting in the binding of an ATP molecule (fig. 1). This results in receptor autophosphorylation and transphosphorylation of another receptor monomer. The autophosphorylation of the receptor incorporates phosphate into several C-terminus tyrosine residues which then become the docking sites for several Src homology 2 (SH2) containing signal transducers [i.e. p85, Grb2/Sos (growth factor receptor-binding protein 2/son of sevenless protein), PLC1 (phospholipase C- 1) etc.] whose role is to transmit the proliferative and survival signals of the receptor downstream. The binding of EGF with one EGFR monomer frequently induces the recruitment and activation of another EGFR monomer. Although homodimerisation of EGFR is freDrugs 2000; 60 Suppl. 1

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quently reported, the heterodimerisation of EGFR with other receptors such as HER-2/neu has also been observed. After ligand-induced activation, EGFR can couple to a number of intracellular proteins involved in signal transduction cascades, including PLC , phosphatidylinositol-3 kinase (PI3K), small G-proteins, p21 Ras, the Ras GTPase activating protein (GAP), growth factor receptor-binding protein 2 (Grb2), and Src family kinases.[5,7,8] Depending on the type of receptor activated and the binding sites that are phosphorylated, different sets of signalling proteins may be activated. As a consequence of this process, different extracellular signals are transmitted to the cell nucleus. The EGFR family of receptors thus have the ability to provide vast signalling diversity, depending on ligand selection, the binding sites for signalling proteins that are activated, and intrinsic substrate specificity for their kinase activities.[8] In addition, several recent communications have emphasised the importance of cross talk between different growth factor receptor signalling pathways. 2. Cellular Effects of EGFR Activation
2.1 Proliferation

occur via unscheduled autocrine ligand synthesis by premalignant cells or, alternatively, by an abnormal distribution of EGFRs.[9]
2.2 Other Biological Effects

The tyrosine kinase activity of EGFR represents its effector function, and is essential for signal transduction and thus eliciting biological responses by the target cell. Among the various responses that arise from ligand binding to the EGFR, the mitogenic response has been extensively studied since cell proliferation is an obvious way by which EGFR can contribute to malignancy. Cells can become malignant by endogenous production of growth factors acting in an autocrine fashion. However, to achieve malignant transformation, EGFR usually needs to be expressed at high levels in addition to the presence of the activating ligand, as cells expressing normal levels of EGFR do not undergo ligand-dependent transformation. Nevertheless, continuous exposure to a ligand can lead to hyperproliferation, and this can
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In addition to proliferation, a variety of other biological responses resulting from EGFR activation are also known to be important for tumour progression, including effects on cell motility, cell adhesion, invasion, cell survival, and angiogenesis (reviewed by Woodburn).[10] The cell movement response initiated by EGFR, i.e. promotion of tumour cell motility, adhesion and invasion, requires tyrosine kinase activity and trans-phosphorylation, and appears to be regulated differently from the mitogenic response. EGF-stimulated alterations in the adhesion of various cancer cells aid in their transmigration to extravascular regions; both EGF and amphiregulin appear to modulate the invasion of metastatic breast cancer cells, and EGFRpositivity has been shown to be an important factor in gastric and colon cancer metastases.[10] As indicated above (section 1.1), TGF and EGF are both potent inducers of angiogenesis, which is a key requirement for continued tumour growth.[10] TGF promotes the expression of vascular endothelial growth factor (VEGF), which increases vascular cell permeability, and coexpression of EGFR and TGF has been reported to exhibit a strong correlation with microvessel density in invasive cancer.[11] An influence on cell survival has been demonstrated by the finding that EGF is anti-apoptotic in cells overexpressing EGFR, a situation that exists in a significant proportion of tumours.[12] Further evidence of this effect has been provided by reports that apoptosis of cancer cells is promoted by EGFR tyrosine kinase inhibitors (TKIs)[13-15] and by an anti-EGFR monoclonal antibody (cetuximab; C225 chimeric mouse/human monoclonal antibody).[16] Induction of apoptosis is a significant feature of the action of anti-EGFR agents, although it may not occur in all circumstances.[10]
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3. EGFR Activation and Tumourigenesis There is now a considerable body of evidence that the EGFR subfamily of tyrosine kinases are implicated in the development and progression of a variety of cancers.[8] Deregulated expression of EGFR and its ligands resulting in aberrant EGFR signalling has been linked with tumourigenesis in numerous studies in both animals and humans[7] and, clinically, a high percentage of tumours in the breast, ovary, head and neck, bladder, colon, oesophagus, cervix, prostate and lung have been found to be associated with loss of physiological regulation of EGFR signalling pathways. Moreover, a correlation has been established in many studies between high expression of EGFR or HER-2 receptors and decreased survival times, e.g. in breast and ovarian cancers.[8, 17-23] Several mechanisms by which deregulated EGFR activity results in malignant cell transformation have been proposed, and include the following: 1. Overexpression of the normal EGFR. This may result from increased transcriptional or posttranscriptional mechanisms or as a consequence of gene amplification. In several cancers, the presence and degree of overexpression are significantly associated with increased malignancy, as estimated by the degree of invasiveness, frequency of relapse, and patient survival.[4] In breast cancer, there is an inverse relationship between EGFR-positivity and estrogen receptor (ER) and progesterone receptor (PR) levels, so that EGFR-positivity is twice as high in ER- or PR-negative tumours in comparison with ER- or PR-positive tumours.[17] 2. Development of receptor mutants that are constitutively active without ligands. The most frequently identified receptor mutant is EGFRvIII, which has lost amino acids 6-273, and this truncation results in ligand-independent tyrosine kinase activity, altered subcellular location, and enhanced tumourigenicity.[7] This mutation has been detected in glial tumours, and in carcinomas of the breast, ovary, prostate and stomach, as well as in non-small cell lung cancer.
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3. Activation of normal receptors by autocrine overproduction of ligands. Increased expression of EGF and TGF, particularly the latter, also gives rise to tumourigenesis.[4,7] Numerous studies have indicated that TGF/EGFR autocrine mechanisms play an important role in many common epithelial cancers. TGF is known to be produced by many different types of tumours but its highest and most consistent synthesis seems to be in the same types that overexpress EGFR, although there is no absolute relationship between their simultaneous overexpression.[4] These findings indicating an important role for aberrant EGFR signalling activity in the development of various human cancers provide a strong rationale for viewing the EGFR subfamily of tyrosine kinase receptors as viable targets for the development of new anticancer therapies. In recent years, a number of strategies that modulate the EFGR itself or inhibit tyrosine kinase phosphorylation or other components of the signalling pathway have been explored. 4. EGFR Tyrosine Kinase as a Target for Anticancer Therapy The development of new potential anticancer therapies that selectively modulate the EGFR signalling pathways activated in precancerous and cancerous conditions has involved several investigative approaches ranging from upstream interference with endogenous ligand binding to downstream interference with signal transduction (fig. 2). Compounds that are currently being investigated include the following: 1. Antibodies that block the extracellular ligandbinding region of the receptor, thereby interfering with its activation and modulating the resultant intracellular signal cascade. This group includes (i) anti-EGFR and anti-HER-2 monoclonal antibodies; (ii) bispecific anti-EGFR or anti-HER-2 monoclonal antibodies linked to an anti-CD64 antibody; (iii) anti-ligand antibodies; and (iv) scFv (singlechain variable region-containing fragment) antibodies conjugated to immunogenic cellular toxins such as Pseudomonas exotoxin A (ETA).[1]
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Immune effector cell

2 Bispecific Abs 1

Anti-ligand MAbs 3 Ligand-toxin conjugates

scFv-toxin conjugates 5 Ligand-genistein conjugates

Anti-receptor MAbs

Ligand binding

Nucleus

Substrate tyrosine phosphorylation

ATP and substrate competitors

Signal transduction

Fig. 2. Potential targets for modulating epidermal growth factor receptor (EGFR) signalling pathways currently being investigated as

part of the development of potential new anticancer agents.[1] Specific examples of agents acting via each approach depicted (1 to 6) include the following: (1) Antireceptor monoclonal antibodies (MAbs): trastuzumab (anti-HER-2 monoclonal antibody); cetuximab (anti-EGFR chimeric mouse/human monoclonal antibody C225); E7.6.3 (anti-EGFR monoclonal antibody ABX); H 447 (bispecific antibody comprising an anti-EGFR monoclonal antibody linked to an anti-CD64 antibody); MDX 210 (bispecific antibody comprising an anti-HER-2 monoclonal antibody linked to an anti-CD64 antibody). (2) Anti-ligand MAbs, i.e. antibodies to the ligands epidermal growth factor (EGF) and transforming growth factor- (TGF): no agents yet shown to be effective in vivo. (3) Ligand-toxin conjugates (EGF and TGF) conjugated to various truncated forms of immunogenic cellular toxins: no agents yet shown to be effective in vivo. (4) scFv (single chain variable region-containing fragment) antibody-toxin conjugates: scFv (14E1)-ETA [single chain anti-EGFR antibody fusion toxin with Pseudomonas exotoxin A (ETA)]; AR 209 (single chain anti-HER-2 antibody fusion toxin with ETA). (5) Ligand-genistein conjugates: EGF-genistein (conjugate of recombinant EGF and genistein, a tyrosine kinase inhibitor). (6) Tyrosine kinase inhibitors (ATP binding site competitors that inhibit tyrosine kinase trans-phosphorylation): (i) Quinazoline inhibitors: ZD1839 (Iressa)1,2; PD 153035; CP 358774 (reversible inhibitors); PD 168393; PD 160678 (irreversible inhibitors); (ii) Pyrazolo-pyrrolopyridopyrimidine inhibitors: PKI 166; STI 571; PD 158780; PD 165557.

2. Ligand-toxin conjugates acting at the extracellular ligand-binding region, e.g. TGF or EGF fused to immunogenic cellular toxins such as ETA, and EGF-genistein fusion protein (a conjugate of recombinant EGF and genistein, a TKI). 3. Inhibitors of tyrosine kinase phosphorylation in the intracellular region of the receptor. These agents interfere with ligand-induced EGFR activity by inhibiting tyrosine trans-phosphorylation, thereby blocking the signalling pathway. They are typically small molecules and are referred to as TKIs. Most compounds currently be Adis International Limited. All rights reserved.

ing developed compete with the ATP-binding site (fig. 2), and have good selectivity for EGFR tyrosine kinase; the majority are reversible inhibitors (see article by Baselga and Averbuch in this supplement [24] ), although several irreversible inhibitors have recently been synthesised.[2,8] Other agents acting at intracellular sites include the following: substrate inhibitors designed to mimic the primary sequence around the tyrosine moiety and substitute nonphosphorylatable peptides at the substrate-binding region
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compounds that inhibit downstream signals by interrupting intracellular protein recognition sequences. At present, however, no compounds in these classes are being investigated clinically.[1] Representative agents in the each of the above classes that are currently undergoing clinical development are shown in figure 2. Among the TKIs under active development, the principal focus this seminar-in-print, are several different structural classes, the most promising of which, and the most advanced in terms of their development, are the quinazoline and pyrazolo-pyrrolo-pyrimidine inhibitors (fig. 2). During the last 5 years, considerable progress has been made in developing agents with apparent specificity for EGFR tyrosine kinase and with favourable pharmacokinetic and pharmacodynamic properties, so that their potential as cancer chemotherapeutic agents is now being explored in clinical trials. An orally active compound, ZD1839 (Iressa),1,2 which has good tolerability and is currently undergoing phase II to III trials, is the focus of other articles appearing in this supplement.
5. EGFR Expression and Sensitivity and Resistance to Cytotoxic Drugs and Radiotherapy Recent studies have provided evidence that antisense-reduced expression of EGF receptors is associated with increased resistance to cisplatin in human breast cancer cell lines that usually express high levels of EGF receptors.[25] On the other hand, experimental elevation of EGFR levels in human cancer cells that normally express low receptor levels leads to increased resistance to a number of anticancer drugs.[26] This suggests that the EGFR level in cancer cells is critical for targeting apoptosis induced by anticancer drugs. In addition, alteration of signal transduction pathways in the EGFR subfamily can strongly influence sensitivity and resistance to many cytotoxic drugs. Moreover, cells expressing multidrug resistance frequently display an increased number of EGF and HER2/neu receptors.[27] As a result, the culture of some
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cell lines with EGF to activate EGF receptors has been shown to enhance sensitivity to several anticancer agents[28] and radiotherapy.[29] Conversely, in other cancer cells that overexpress EGF and/or HER-2/neu, chemosensitivity to cisplatin, doxorubicin, and etoposide was found to be enhanced by exposure to tyrphostin, an inhibitor of HER-2/neu receptor tyrosine kinase, and EGFR monoclonal antibodies.[30] Mechanisms that could explain these interactions between EGFR pathways and drug-induced apoptotic pathways remain to be elucidated.[31] Considering that EGFR expression of cancer cells is likely to differ from one patient to another, these findings support attempts to measure EGFR expression in human tumour biopsies prior to using combinations of EGFR inhibitors, cytotoxic drugs and radiotherapy in patients who are undergoing clinical trials with signalling inhibitors for advanced cancer. In addition, redundant signalling pathways are frequently used by tumour cells to proliferate. The combination of multiple agents that simultaneously inhibit several signal transduction kinases is likely to be required to actively control the proliferation of cancer cells. Again, this will require an ability to identify which signalling pathways are critical in individual patients. The tailoring of treatment based on the expression of target proteins and/or critical signalling pathways in cancer cells will be required for the use of specific signal transduction inhibitors. The evaluation of cancer cells taken directly from tumours in patients before and during treatment with signalling inhibitors is likely to be a valuable tool to optimise the use of these new drugs, either alone or in combination with classical anticancer strategies. 6. Conclusions In recent years, significant progress has been made in understanding the structure and functions of the EGFR subfamily of tyrosine kinases. Among the various tyrosine kinase-modulated responses that arise from the binding of endogenous ligands
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such as EGF and TGF to the EGFR, the mitogenic response has been widely studied, since cell proliferation is an obvious way by which EGFR contributes to the development and progression of various cancers. In addition, a number of other EGFRmodulated responses that contribute to malignant behaviour have also been identified, including effects on cell motility, cell adhesion, invasion, cell survival, and angiogenesis. A considerable body of evidence has now been accumulated implicating aberrant EGFR signal transduction in various malignancies, the mechanisms for which include overexpression of the normal receptor, development of receptor mutants that are constitutively active without a ligand, and autocrine overproduction of ligands, particularly TGF. In certain cancers, an important correlation has been established between overexpression of EGFR and/or its ligands and a poor clinical prognosis. Increased knowledge of the role of EGFR tyrosine kinase activity in tumourigenesis has given rise to substantial research efforts to develop new anticancer therapies that target various components of the EGFR signal transduction pathway. Among the approaches currently being investigated are agents that target either the extracellular or intracellular regions of the receptor. The former include various monoclonal antibodies that interfere with receptor activation and thereby modulate the resultant intracellular signal cascade. The latter include small molecule TKIs, which modulate ligand-induced EGFR activity via inhibition of tyrosine kinase trans-phosphorylation and consequently block the signalling pathway. During the last 5 years, considerable progress has been made in developing EGFR-selective TKIs that act by interfering with ATP binding, and these drugs offer the possibility of inhibiting specific deregulated pathways in cancerous and precancerous cells while having minimal effects on normal cell function. A number of TKIs currently being developed have been found to have favourable pharmacokinetic and pharmacodynamic properties and low toxicity, and these agents are now undergoing phase II to III clinical trials. In addition, the accu Adis International Limited. All rights reserved.

mulation of evidence from laboratory studies strongly suggests that EGFR-selective TKIs will have synergistic effects with other antitumour agents or therapy such as cytostatic agents, conventional cytotoxic drugs and radiotherapy. Improved molecular understanding of signal transduction pathways will undoubtedly see further advances in this area, and allow the therapeutic potential of these compounds to be realised. References
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25. Dixit M, Yang JL, Poirier MC, et al. Abrogation of cisplatin-induced programmed cell death in human breast cancer cells by epidermal growth factor antisense RNA. J Natl Cancer Inst 1997; 89: 365-73 26. Dickstein BM, Wosikowski K, Bates SE. Increased resistance to cytotoxic agents in ZR75B human breast cancer cells transfected with epidermal growth factor receptor. Mol Cell Endocrinol 1995; 110: 205-11 27. Dickstein B, Valverius EM, Wosikowski K, et al. Increased epidermal growth factor receptor in an estrogen-responsive, adriamycin-resistant MCF-7 cell line. J Cell Physiol 1993; 157: 110-8 28. Kroning R, Jones JA, Hom DK, et al. Enhancement of drug sensitivity of human malignancies by epidermal growth factor. Br J Cancer 1995; 72: 615-9 29. Bonner JA, Maihle NJ, Folven BR, et al. The interaction of epidermal growth factor and radiation in human head and neck squamous cell carcinoma cell lines with vastly different radiosensitivity. Int J Radiat Oncol Biol Phys 1994; 29: 243-7 30. Tsai CM, Levitzki A, Wu LH, et al. Enhancement of chemosensitivity by tyrphostin AG825 in high-p185neu expressing non-small cell lung cancer cells. Cancer Res 1996; 56: 1068-74 31. Mendelsohn J. Epidermal growth factor receptor inhibition by monoclonal antibody as anticancer therapy. Clin Cancer Res 1997; 3: 2703-07

Correspondence and offprints: Dr E. Raymond, Department of Medicine, Institute Gustave-Roussy, 39 rue Camille Desmoulins, 94815 Villejuif-Cedex, France. E-mail: raymond@igr.fr

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