Overcoming Barriers Gliadel Wafers As a Case Study

OVERCOMING BARRIERS GLIADEL WAFERS AS A CASE STUDY

Henry Brem Harvey Cushing Professor Neurosurgery, Ophthalmology, Oncology & Biomedical Engineering Chairman - Department of Neurosurgery Johns Hopkins University

THE INSITUTE FOR CLINICAL AND TRANSLATIONAL RESEARCH TRANSLATIONAL RESEARCH COMMUNITIES THE JOHNS HOPKINS UNIVERSITY OWENS AUDITORIUM, CANCER RESEARCH BLDG July 9,, 2014 Malignant Astrocytoma: Survival

Months BRAIN TUMORS

• In 1984 – many systemic treatments had been tried with no benefit.

• The FDA had not approved any new therapy in over 20 years. Glioblastoma: Treatment Outcome

10 10 9.25

4 4

Median Survival (Months) 2

0 Surgery Only Surgery + Surgery + Radiotherapy Radiotherapy + Chemotherapy

McDonald JD, Rosenblum ML: In: Rengachary SS, Wilkins RH, eds. Principles of Neurosurgery. St Louis, MO: Mosby-Wolfe; 1994: chap 26. DRUG DELIVERY AND TARGETING • GOAL IS TO IMPROVE QUALITY AND LENGTH OF LIFE

• IMPROVING EFFECTIVENESS AND MINIMIZING UNWANTED SIDE EFFECTS TARGETED BRAIN TUMOR THERAPY

1. BRAIN DELIVERY OF EFFECTIVE AGENTS

2. DIRECTING TO RESPONSIBLE CELLS (CANCER, VESSELS, IMMUNE, STEM)

3. INDIVIDUALIZED THERAPY

Problem: Clinical effectiveness of new cancer therapies

Hypothesis: Better delivery of agents to target sites would improve outcome

Solution: Targeted controlled delivery (polymers)

Preclinical Studies

• Safety - Implantation in cornea and brain - Rats, Rabbits, and Monkeys • Drug Distribution - Autoradiography: rats, rabbits, monkeys • Efficacy - Rodent models

This approach will not work because:

• Polymers cannot be synthesized (1981) • Polymers will react with encapsulated drugs (1983) • These polymers are fragile (1985) • The polymer drug system would be toxic (1987) • Drugs would not diffuse far enough (1989) • Models do not reflect clinical reality (1991) • BCNU is a very poor drug (1993) • FDA approval would be impossible for a polymer system (1995) • How will it be paid for? (1997) • Which patients will maximally benefit? (1999) • Would the FDA broaden the indications? (2003) •Precludes phase I studies (2005) •Need better targeted drugs! (2007….) •Need more sophisticated delivery approaches (eg Microchips, Ultrasound and nano-technology) (2014)

GLIADEL IMPLANTABLE BCNU WAFERS: Temozolomide and Gliadel have similar survival benefit for GBM patients

TMZ Overall Survival GLIADEL Overall Survival

100 90 Placebo GLIADEL 80 Median OS, mo: 10.9 13.1 p=0.031 2-yr survival: 6% 20% 70 HR [95% C.I.]: 0.75 [0.58-0.98] 60 p=0.034 50 40 30 Survival Rate (%) Survival 20 GLIADEL 10 Placebo 0 0 3 6 9 12 15 18 21 24 28 32 36 40 44 Hazard Ratio = 0.75 Months from Implant Surgery Stupp et al, ASCO, 2004 (www.asco.org). Meldorf M et al. AANS, 2003 (Abstract 1492).

Local and systemic administration of Temozolomide in the 9L gliosarcoma model

100

80 Control Oral Temozolomide 50mg/kg 60 50% Temozolomide:CPP:SA

40 2 x 50% Temozolomide:CPP:SA Time (days) Time 20

0 0 20 40 60 80 Percent Survival Efficacy of BCNU and 50% TMZ against an Established 9L Glioma Model

100 Control

80 3.8% BCNU 60 50% TMZ 40

Percent Survival Percent 20 50% TMZ + 3.8% BCNU

0 BCNU vs. control, p<0.04 TMZ vs. control, p<0.01 0 50 100 150 BCNU+TMZ, p<0.0001 vs. BCNU p<0.016 vs. TMZ Time (Days) Combinations

• Combinations are currently under investigation in the laboratory and in clinical trials.

2014

18 YEARS AFTER FDA APPROVAL, GLIADEL IS USED WIDELY THROUGHOUT THE WORLD GLIADEL DEVELOPMENT 1985 – 2014 • Nova • Scios Nova • Guilford • Rhone Poulenc Rhorer • Aventis • Guilford • MGI PHARMA • Eisai Co, LTD • Arbor Pharmaceuticals (Dec 19, 2012 for United States) Brain Tumor Therapy

• These improvements are only the beginning and there is much more now in the “pipeline”

• However, none of this would have been possible if not for reaching across borders between specialties, academic centers, industry, NIH, FDA, Patient Advocate Groups, Congress and CMS as well as international regulatory agencies! NEW TREATMENTS AND DELIVERY APPROACHES MICROCHIPS INDIVIDUALIZED THERAPY Active Device - 3mm

TMZ loaded in chamber

Site opens for payload release

100 9L Control 90 Unactivated Device 3 Membranes, Day 0 80 3 Membranes, Day 3 70 3 Membranes, Day 5 60 50 40 Survival (%) 30 20 10 0 0 10 20 30 40 50 60 110 120 Time (days) Nature Materials, 2003 Nov;2(11):767-72

Brain Tumor Therapy

•NEWER AGENTS and TARGETS The challenge is to choose the most promising biological therapies for development and widest application. AgentsAgents in in Pre Pre-Clinical-Clinical Development at atthe the Hunterian Hunterian Laboratory Laboratory Chemotherapy Mechanism of Action Reference ChemotherapyAdriamycin (Doxorubicin) MechanismIntercalates of Action DNA ReferenceAnti Can Res 2005 AdriamycinBCNU (Doxorubicin) Intercalates DNA Alkylating agent Anti Can Res 2005 J Control Rel 2007 BCNU Camptothecin AlkylatingTopoisomerase agent inh J ControlClin Rel Can2007 Res 2006 Camptothecin Topoisomerase inh Clin Can Res 2006 Carboplatin Alkylating agent Childs Nerv Syst 2009 Carboplatin Alkylating agent Childs Nerv Syst 2009 Cyclophosphamide Alkylating agent JNS1995 Cyclophosphamide Alkylating agent JNS1995 Docetaxel Docetaxel Mitotic InhibitorMitotic Inhibitor JNO 2006 JNO 2006 Epirubicin Epirubicin Intercalates DNAIntercalates DNA JNO 2010 JNO 2010 MethotrexateMethotrexate Inhibits DNAInhibits synthesis DNA synthesis Can Res 1994Can Res 1994 Mitoxantrone Mitoxantrone Type II TopoisomeraseType II Topoisomerase Inh Inh JNS 2002 JNS 2002 OncoGel (Taxol)OncoGel (Taxol) Mitotic InhibitorMitotic Inhibitor JNS 2009 JNS 2009 Paclitaxel Paclitaxel Mitotic InhibitorMitotic Inhibitor JNO 2006 JNO 2006 TemozolomideTemozolomide AlkylatingAlkylating agent agent NeurosurgeryNeurosurgery 2010 2010 Angiogenesis inhibitors Angiogenesis inhibitors BevacizumabBevacizumab VEGF InhibitorVEGF Inhibitor AANS 2010AANS 2010 Endostatin Angiogenesis inhibitor Neurosurgery 2005 Endostatin Angiogenesis inhibitor Neurosurgery 2005 mFc-endostatin Angiogenesis inhibitor In preparation MinocyclinemFc - endostatin AngiogenesisAngiogenesis inhibitor inhibitor JNO 2003 In preparation Rapamycin Minocycline mTOR inhibitorAngiogenesis inhibitor In review JNO 2003 Squalamine Rapamycin AngiogenesismTOR inhibitor inhibitor Can Res 1998In review ImmunotherapySqualamine Angiogenesis inhibitor Can Res 1998 TGF-alpha-PE38 AntineoplasticImmunotherapy Agent Can Res 1994 IL-2 TGF-alpha-PE38 T cell stimulatorAntineoplastic Agent JNO 2005 Can Res 1994 IL-4 IL-2 B and T cell StimulatorT cell stimulator Neurosurg FocusJNO 20002005 IL-12 IL-4 T cell stimulatorB and T cell Stimulator AnticancerNeurosurg Drugs Focus2008 2000 GM-CSFIL-12 StimulatesT cell stem stimulator cells J ImmunotherAnticancer 1996 Drugs 2008 MolecularGM Targets-CSF Stimulates stem cells J Immunother 1996 A-443654 AKT Inhibitor Mol Cancer Ther 2009 Molecular Targets L-Buthionine Sulfoximine Alkylating inactivator Neurosurgery 2001 ClostridiumA-443654 perfringens enterotoxin InducesAKT cytolysis Inhibitor CancerMol Res Cancer 2007 Ther 2009 Fas ligandL-Buthionine Sulfoximine Induces apoptosisAlkylating inactivator NeuroOncol,Neurosurgery 2010 2001 LactacystinClostridium perfringens enterotoxin Induces apoptosisInduces cytolysis NeuroOncolCancer 2006 Res 2007 O6-BenzylguanineFas ligand Inhibits AGTInduces DNA apoptosis repair Can Res NeuroOncol,2000 2010 Riluzole Lactacystin Glu tamateInduces Receptor apoptosis Ant SFN 2004NeuroOncol 2006 AmphibinaseO6-Benzylguanine AntineoplasticInhibits RNAse AGT DNA repair Pharm ResCan 2009 Res 2000 Riluzole Glu tamate Receptor Ant SFN 2004 Amphibinase Antineoplastic RNAse Pharm Res 2009UpdatedUpdated 6/2010 6/2010 AgentsAgents in in Pre Pre-Clinical-Clinical Development at atthe the Hunterian Hunterian Laboratory Laboratory

Chemotherapy Mechanism of Action Reference Adriamycin (Doxorubicin) Intercalates DNA Anti Can Res 2005 BCNU Alkylating agent J Control Rel 2007 Camptothecin Topoisomerase inh Clin Can Res 2006 Carboplatin Alkylating agent Childs Nerv Syst 2009 Cyclophosphamide Alkylating agent JNS1995 Docetaxel Mitotic Inhibitor JNO 2006 Epirubicin Intercalates DNA JNO 2010 Methotrexate Inhibits DNA synthesis Can Res 1994 Mitoxantrone Type II Topoisomerase Inh JNS 2002 OncoGel (Taxol) Mitotic Inhibitor JNS 2009 Paclitaxel Mitotic Inhibitor JNO 2006 Temozolomide Alkylating agent Neurosurgery 2010 Angiogenesis inhibitors Bevacizumab VEGF Inhibitor AANS 2010 Endostatin Angiogenesis inhibitor Neurosurgery 2005 mFc-endostatin Angiogenesis inhibitor In preparation Minocycline Angiogenesis inhibitor JNO 2003 Rapamycin(Sirolmus) mTOR inhibitor In review Squalamine Angiogenesis inhibitor Can Res 1998 Immunotherapy TGF-alpha-PE38 Antineoplastic Agent Can Res 1994 IL-2 T cell stimulator JNO 2005 IL-4 B and T cell Stimulator Neurosurg Focus 2000 IL-12 T cell stimulator Anticancer Drugs 2008 GM-CSF Stimulates stem cells J Immunother 1996 Molecular Targets A-443654 AKT Inhibitor Mol Cancer Ther 2009 L-Buthionine Sulfoximine Alkylating inactivator Neurosurgery 2001 Clostridium perfringens enterotoxin Induces cytolysis Cancer Res 2007 Fas ligand Induces apoptosis NeuroOncol, 2010 Lactacystin Induces apoptosis NeuroOncol 2006 O6-Benzylguanine Inhibits AGT DNA repair Can Res 2000 Riluzole Glu tamate Receptor Ant SFN 2004 Amphibinase Antineoplastic RNAse Pharm Res 2009

Updated 6/2010 Key Pathways in Brain Cancer

Nano-Delivery Platforms