Purpose: Vanucizumab is an investigational antiangiogenic, first-in-class, bispecific mAb targeting VEGF-A and angiopoietin-2 (Ang-2). This first-in-human study evaluated the safety, pharmacokinetics, pharmacodynamics, and antitumor activity of vanucizumab in adults with advanced solid tumors refractory to standard therapies.

Experimental Design: Patients received escalating biweekly (3–30 mg/kg) or weekly (10–30 mg/kg) intravenous doses guided by a Bayesian logistic regression model with overdose control.

Results: Forty-two patients were treated. One dose-limiting toxicity, a fatal pulmonary hemorrhage from a large centrally located mediastinal mass judged possibly related to vanucizumab, occurred with the 19 mg/kg biweekly dose. Arterial hypertension (59.5%), asthenia (42.9%), and headache (31%) were the most common toxicities. Seventeen (41%) patients experienced treatment-related grade ≥3 toxicities. Toxicity was generally higher with weekly than biweekly dosing. A MTD of vanucizumab was not reached in either schedule. Pharmacokinetics were dose-linear with an elimination half-life of 6–9 days. All patients had reduced plasma levels of free VEGF-A and Ang-2; most had reductions in KTRANS (measured by dynamic contrast-enhanced MRI). Two patients (renal cell and colon cancer) treated with 30 mg/kg achieved confirmed partial responses. Ten patients were without disease progression for ≥6 months. A flat-fixed 2,000 mg biweekly dose (phamacokinetically equivalent to 30 mg/kg biweekly) was recommended for further investigation.

Conclusions: Biweekly vanucizumab had an acceptable safety and tolerability profile consistent with single-agent use of selective inhibitors of the VEGF-A and Ang/Tie2 pathway. Vanucizumab modulated its angiogenic targets, impacted tumor vascularity, and demonstrated encouraging antitumor activity in this heterogeneous population. Clin Cancer Res; 24(7); 1536–45. ©2017 AACR.

This article is featured in Highlights of This Issue, p. 1511

Translational Relevance

Treatment of cancer by targeting VEGF-A with bevacizumab has been extensively validated in the clinic. However, not all tumors respond to VEGF-A blockade and escape mechanisms due to overlapping and compensatory pathways can limit the full potential of antiangiogenic agents. Angiopoietin-2 (Ang-2) and VEGF-A have complementary roles in regulating tumor angiogenesis and metastasis, suggesting that dual pathway inhibition is necessary to improve treatment outcomes. Vanucizumab is an investigational, first-in-class, bispecific IgG1-like mAb using CrossMab technology that simultaneously blocks VEGF-A and Ang-2 from interacting with their receptors. This first-in-human study demonstrated an acceptable safety and tolerability profile for vanucizumab in patients with advanced solid tumors. A MTD was not reached with either vanucizumab schedule (weekly/biweekly) tested at the highest dose (30 mg/kg). Vanucizumab also demonstrated consistent pharmacokinetic and pharmacodynamic effects, and showed encouraging signs of antitumor activity that support further evaluation of vanucizumab in clinical trials.

Targeting angiogenesis is an attractive therapeutic approach in many cancers (1). Several inhibitors of the VEGF receptor (VEGFR) and family of ligands are approved, including the anti-VEGF-A mAb bevacizumab; the anti-VEGFR2 mAb ramucirumab; the dual VEGF-A/placenta growth factor (PlGF) inhibitor aflibercept; and the tyrosine kinase inhibitors sunitinib, sorafenib, pazopanib, regorafenib, and axitinib. Bevacizumab plus chemotherapy prolongs patient survival in many cancers compared with chemotherapy alone (2). However, patients who respond to VEGF/VEGFR inhibition invariably develop resistance due to activation of compensatory angiogenic signaling pathways (3).

Resistance to VEGF-targeted therapies may be partly mediated by Angiopoietin-1 and 2 (Ang-1 and Ang-2), the functional ligands of the Tie2 receptor tyrosine kinase found on endothelial cells (4, 5). Binding of Ang-1 to Tie2 stabilizes new blood vessels leading to maturation, whereas binding of Ang-2 to Tie2 triggers angiogenic sprouting and increased vessel plasticity (6). A shift in the Ang-1/Ang-2 ratio toward Ang-2 therefore represents a proangiogenic switch. Tumors expressing high levels of Ang-2 have a poor prognosis (7–10) and poor response to bevacizumab-based therapy (11, 12) and sunitinib (13). Several Ang-2 pathway inhibitors have been developed including the Ang-1/Ang-2–neutralizing peptibody trebananib (AMG 386); the fusion proteins CVX-060 and CVX-241(the latter binds both Ang-2 and VEGF); and the Tie2 receptor inhibitors ARRY614 and CEP-11981.

Dual Ang-2 and VEGF-A inhibition is attractive as both pathways show complementary and synergistic actions during tumor angiogenesis (14, 15). Tumors with elevated levels of both proteins have a worse prognosis than those expressing high levels of either protein alone (8, 16). Vanucizumab (RG7221/RO5520985) is a novel humanized IgG1-like bispecific mAb established using CrossMAb technology that binds both Ang-2 and VEGF-A with high affinity (17, 18). Vanucizumab inhibited angiogenesis, tumor growth, and metastasis formation in vivo more effectively than mono-specific anti-Ang-2 or anti-VEGF-A mAbs, and reduced microvessel density and promoted vessel maturation in a murine breast cancer model (17, 18). Normalization of vessel architecture appeared to improve chemotherapy drug delivery; combining vanucizumab with docetaxel resulted in complete and long-term tumor regression in vivo (18). Importantly, vanucizumab did not aggravate the known adverse effect of anti-VEGF-A treatment on healthy vessels.

Here we report results from part I of the first-in-human phase I study that investigated the MTD and/or recommended phase II dose (RP2D) of vanucizumab in patients with locally advanced or metastatic solid tumors.

The study was conducted according to the principles of the Declaration of Helsinki and was registered (clinicaltrials.gov NCT01688206). Institutional Review Board approval and written informed consents were obtained before study-related procedures commenced.

Eligibility criteria

Inclusion criteria included age ≥18 years; histologically/cytologically confirmed locally advanced or metastatic, nonresectable solid tumors that progressed despite standard therapy, or where no standard therapy existed; measurable disease by Response Evaluation Criteria In Solid Tumors (RECIST) version 1.1 criteria; Eastern Cooperative Oncology Group performance status ≤1; and adequate hematologic, coagulative, hepatic, renal, and cardiovascular function. Exclusion criteria included unstable primary central nervous system tumors or metastasis; squamous non–small cell lung cancer histology; hemoptysis grade (G) ≥2 within 4 weeks; bleeding diathesis or coagulopathy; major surgery within 4 weeks; anticancer therapy within 4–6 weeks (6 months for agents targeting VEGF/Ang-1/Ang-2/PlGF pathways); significant cardiovascular/cerebrovascular disease; or abdominal fistula/gastrointestinal perforation within 6 months.

Study design

This was part I (dose-escalation) of a four-part first-in-human, open-label, multicenter, phase I study. The primary objective was to determine the MTD and/or RP2D of vanucizumab. Secondary objectives were to characterize the safety, tolerability, pharmacokinetics, pharmacodynamics, and preliminary antitumor activity of single-agent vanucizumab.

Vanucizumab was administered by intravenous infusion without premedication on day (D) 1 of each cycle with two dosing schedules: weekly and biweekly. One cycle (C) corresponded to one vanucizumab dose. Vanucizumab was infused over 90 minutes for the first infusion. If the first and second infusion were tolerated without signs and symptoms of infusion-related reactions (CTCAE G≥2), the second and all subsequent infusions were administered over 60 and 30 minutes, respectively.

The starting dose of 3 mg/kg for biweekly dosing was determined on the basis of nonclinical toxicology and efficacy studies, anticipated efficacious concentration based on dynamic pharmacokinetic/pharmacodynamic modeling, and subsequent prediction of the human pharmacokinetics of vanucizumab. This dose was anticipated to result in safety margins of 26-fold based on the AUCτ to the exposure at the highest nonseverely toxic dose of 60 mg/kg and 52-fold based on Cmax. This dose was close to the predicted minimum efficacious dose of 3.5 mg/kg. One patient was enrolled at the 3 mg/kg biweekly starting dose and at least three patients in subsequent cohorts. The first patient at each dose level was monitored for the first five days of C1. If no dose-limiting toxicity (DLT) occurred, the remaining patients in the cohort were treated simultaneously.

Dose escalation was guided by an Escalation With Overdose Control model with modified continual reassessment (Supplementary Methods; refs. 19, 20). This method seeks a dose level close to the MTD by using toxicity data (incidence of DLTs) from evaluable patients to estimate a dose–toxicity curve and minimizes the number of patients treated at possibly pharmacologically inactive doses. To our knowledge, this is the first reported phase I entry-into-human study to employ a continual reassessment method (CRM) design to assess the safety/tolerability at escalating dose levels of an investigational, large-molecule antiangiogenic drug.

Intra-patient dose escalation to a higher dose already considered safe was allowed after C6 (biweekly) and C12 (weekly).

DLTs, MTD, and RP2D

Toxicities were graded according to Common Terminology Criteria for Adverse Events version 4.03. A DLT was defined as an adverse event (AE) considered study drug–related occurring during the 28-day observation period (42 days in case of treatment delays) that met the criteria listed in Supplementary Table S1. The MTD was defined as the predicted dose at which the probability of DLT rate was 33%. The prediction was based on two-parameter logistic dose–toxicity relationship model using a uniform prior for the toxicity at the starting dose and a truncated normal prior for the MTD.

The RP2D was selected on the basis of the integrated analysis of clinical safety/tolerability, antitumor activity, pharmacodynamic (including functional imaging), and pharmacokinetic data. Once a suitable dose had been established, pharmacokinetic modeling and simulation was conducted to identify a flat-fixed dose that had comparable steady-state systemic exposures, peak, and trough concentrations.

Pharmacokinetics

Blood for pharmacokinetic assessments was taken during C1, C2, and C4 at predose, 0.5 hours, end-of-infusion, and 2, 4, 6, 24, 96, and 168 (biweekly cohort only) hours post start of infusion. From C5, predose and end-of-infusion samples were taken every cycle (biweekly) or every second cycle (weekly). Additional samples were taken upon the occurrence of DLTs, dose reductions, disease response/progression, or study discontinuation. Plasma vanucizumab was measured using a validated ELISA (lower limit of quantification 1.00 ng/mL). Pharmacokinetic parameters were estimated using noncompartmental analysis (Supplementary Methods) with Phoenix WinNonlin (v6.2; Pharsight). Anti-drug antibodies (ADA) were measured using a bridging ELISA at baseline, every 4 weeks, and upon occurrence of a G≥3 hypersensitivity reaction, to assess the potential immunogenicity of vanucizumab.

Pharmacodynamics

Circulating free and total (drug-bound and unbound) VEGF-A and Ang-2 levels were measured (see Supplementary Methods) in plasma obtained at baseline and D1, D2, D5 (biweekly), D8 (weekly), D15 (biweekly only), D18 (weekly only) D29, D57, and at disease progression/study discontinuation.

Multiparametric diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) MRI scans were performed twice at baseline (≥2 days apart) and on D5, D15, and D29 (biweekly dosing), or D8 and D18 (weekly dosing). Target lesions were selected on the basis of contrast uptake and lesion size (≥2/≥3 cm in areas subject to low/high respiratory motion, respectively). Parameters evaluated comprised KTRANS derived from Extended Toft model, the blood gadolinium-normalized area under the gadolinium concentration–time curve (AUCBN), and the apparent diffusion coefficient (ADC). Images were analyzed independently (VirtualScopics) blinded to the administered vanucizumab dose.

Response evaluation

Tumors were assessed using CT or MRI per RECIST criteria (version 1.1) at baseline and every 8 ± 1 weeks thereafter.

Statistical analysis

The planned sample size for this dose-escalation part of the study was 18 (minimum) to 60 (maximum) patients. Descriptive statistics were presented for all data. Logarithmically transformed, dose-normalized values of the area under the concentration–time curve from 0 hours to time t (AUC0–t), minimum concentration (Cmin), and maximum concentration (Cmax) were analyzed separately by regimen using a linear mixed-effect model to evaluate accumulation and dose proportionality. Population pharmacokinetics and the relationship between pharmacokinetic, pharmadynamic biomarkers, and safety parameters were explored using nonlinear mixed-effect modeling (NONMEM version VI, ADVAN4, GloboMax LLC).

Between October 2012 and November 2013, 42 patients (Table 1) were enrolled and treated at seven dose levels. Patients received a median of eight cycles of vanucizumab on both schedules [range 1–70 (biweekly) and 2–56 (weekly)]. The overall median treatment duration was 63 days. Twenty-two (52.4%) patients were treated on the biweekly schedule [3 mg/kg (n = 1), 6 mg/kg (n = 3), 12 mg/kg (n = 4), 19 mg/kg (n = 8), 30 mg/kg (n = 6)], and 20 (47.6%) patients on the weekly schedule [10 mg/kg (n = 4), 20 mg/kg (n = 4), 30 mg/kg (n = 12)]. At the data cutoff (December 02, 2016), 41 patients had discontinued the study due to disease progression (n = 34), consent withdrawal (n = 1), and toxicities (n = 6). The six toxicities leading to withdrawal were all assessed as study drug related by the investigator and comprised one death (described below); cerebral hemorrhage (G2), hypertension (G3), thrombotic microangiopathy (G3), and hypertensive encephalopathy (G4) all at 30 mg/kg weekly vanucizumab and vesicocutaneous fistula (G3) at 12 mg/kg biweekly vanucizumab.

Table 1.

Baseline demographics and disease characteristics of the treated patients (N = 42)

CharacteristicsValue
Gender (male, female) 18, 24 
Median age (range), years 63 (25–76) 
Tumor stage at time of first diagnosis, n (%) 
 III 11 (26.2) 
 IV 18 (42.9) 
 Other 13 (31.0) 
Tumor stage at time of study entry, n (%) 
 Metastatic 40 (95.2) 
 Locally advanced 2 (4.8) 
Tumor type, n (%) 
 Colon cancer 13 (31.0) 
 Breast cancer 3 (7.1) 
 Cervical cancer 3 (7.1) 
 Ovarian cancer 2 (4.8) 
 Gastric cancer 2 (4.8) 
 Pancreatic cancer 2 (4.8) 
 Rectum cancer 2 (4.8) 
 Uterine leiomyosarcoma 2 (4.8) 
 Cancer of unknown primary 2 (4.8) 
 Adenoid cystic carcinoma 2 (4.8) 
 Endometrial cancer 2 (4.8) 
 Othera 7 (16.7) 
Median previous lines of therapy (range) 3 (1–10) 
 Antimetabolites, n (%) 33 (78.6) 
 Platinum compounds, n (%) 31 (73.8) 
 Topoisomerase inhibitors, n (%) 25 (59.5) 
 Cytotoxic agents, n (%) 19 (45.2) 
 Radiotherapy, n (%) 17 (40.5) 
 Bevacizumab 8 (19.0) 
CharacteristicsValue
Gender (male, female) 18, 24 
Median age (range), years 63 (25–76) 
Tumor stage at time of first diagnosis, n (%) 
 III 11 (26.2) 
 IV 18 (42.9) 
 Other 13 (31.0) 
Tumor stage at time of study entry, n (%) 
 Metastatic 40 (95.2) 
 Locally advanced 2 (4.8) 
Tumor type, n (%) 
 Colon cancer 13 (31.0) 
 Breast cancer 3 (7.1) 
 Cervical cancer 3 (7.1) 
 Ovarian cancer 2 (4.8) 
 Gastric cancer 2 (4.8) 
 Pancreatic cancer 2 (4.8) 
 Rectum cancer 2 (4.8) 
 Uterine leiomyosarcoma 2 (4.8) 
 Cancer of unknown primary 2 (4.8) 
 Adenoid cystic carcinoma 2 (4.8) 
 Endometrial cancer 2 (4.8) 
 Othera 7 (16.7) 
Median previous lines of therapy (range) 3 (1–10) 
 Antimetabolites, n (%) 33 (78.6) 
 Platinum compounds, n (%) 31 (73.8) 
 Topoisomerase inhibitors, n (%) 25 (59.5) 
 Cytotoxic agents, n (%) 19 (45.2) 
 Radiotherapy, n (%) 17 (40.5) 
 Bevacizumab 8 (19.0) 

aOne case each of bladder cancer, renal cell cancer, soft tissue (Ewing) sarcoma, thyroid cancer, non–small cell lung cancer, hypopharyngeal cancer, and ovarian/endometrial cancer.

DLT and MTD

Vanucizumab was reasonably well tolerated across dose levels and schedules. The MTD was not reached. One DLT (hemoptysis with fatal outcome) occurred in a female with colorectal cancer and a large, centrally located mediastinal mass. This patient received two doses of 19 mg/kg biweekly vanucizumab and died on D25.

Safety

The most common AEs were hypertension, asthenia, headache, and diarrhea (Table 2). Thirteen (31%) patients experienced 14 serious AEs (SAE); including seven SAEs considered to be study drug-related: cerebral hemorrhage, hypertension, hypertensive encephalopathy, and thrombotic microangiopathy (all 30 mg/kg weekly); vesicocutaneous fistula (12 mg/kg biweekly); hemoptysis (19 mg/kg biweekly); and blood creatinine increase (30 mg/kg biweekly).

Table 2.

Adverse events regardless of relationship to vanucizumab occurring in ≥10% of the total population (N = 42)

NCI-CTCAE
Adverse event, n (%) MedDRA preferred termGrade 1/2Grade 3/4a,bTotal, n (%)
Hypertension 11 (26.2) 14 (33.3) 25 (59.5) 
Asthenia 17 (40.5) 1 (2.4) 18 (42.9) 
Headache 12 (28.6) 1 (2.4) 13 (31.0) 
Diarrhea 10 (23.8) 1 (2.4) 11 (26.2) 
Cough 10 (23.8) — 10 (23.8) 
Back pain 9 (21.4) — 9 (21.4) 
Constipation 9 (21.4) — 9 (21.4) 
Fatigue 8 (19.0) — 8 (19.0) 
Vomiting 8 (19.0) — 8 (19.0) 
Dysphonia 7 (16.7)  7 (16.7) 
Anxiety 6 (14.3) — 6 (14.3) 
Arthralgia 6 (14.3) — 6 (14.3) 
Dyspnea 6 (14.3) — 6 (14.3) 
Musculoskeletal pain 6 (14.3) — 6 (14.3) 
Nausea 6 (14.3) — 6 (14.3) 
Toothache 6 (14.3) — 6 (14.3) 
Abdominal pain 4 (9.5) 1 (2.4) 5 (11.9) 
Decreased appetite 5 (11.9) — 5 (11.9) 
Edema peripheral 5 (11.9) — 5 (11.9) 
Proteinuria 4 (9.5) 1 (2.4) 5 (11.9) 
NCI-CTCAE
Adverse event, n (%) MedDRA preferred termGrade 1/2Grade 3/4a,bTotal, n (%)
Hypertension 11 (26.2) 14 (33.3) 25 (59.5) 
Asthenia 17 (40.5) 1 (2.4) 18 (42.9) 
Headache 12 (28.6) 1 (2.4) 13 (31.0) 
Diarrhea 10 (23.8) 1 (2.4) 11 (26.2) 
Cough 10 (23.8) — 10 (23.8) 
Back pain 9 (21.4) — 9 (21.4) 
Constipation 9 (21.4) — 9 (21.4) 
Fatigue 8 (19.0) — 8 (19.0) 
Vomiting 8 (19.0) — 8 (19.0) 
Dysphonia 7 (16.7)  7 (16.7) 
Anxiety 6 (14.3) — 6 (14.3) 
Arthralgia 6 (14.3) — 6 (14.3) 
Dyspnea 6 (14.3) — 6 (14.3) 
Musculoskeletal pain 6 (14.3) — 6 (14.3) 
Nausea 6 (14.3) — 6 (14.3) 
Toothache 6 (14.3) — 6 (14.3) 
Abdominal pain 4 (9.5) 1 (2.4) 5 (11.9) 
Decreased appetite 5 (11.9) — 5 (11.9) 
Edema peripheral 5 (11.9) — 5 (11.9) 
Proteinuria 4 (9.5) 1 (2.4) 5 (11.9) 

Abbreviations: MedDRA; Medical Dictionary for Regulatory Activities; NCI-CTCAE, National Cancer Institute-Common Terminology Criteria for Adverse Events.

aOne patient had a G5 event (a DLT of pulmonary hemorrhage in a patient treated with 19 mg/kg biweekly).

bOther G3/4 AEs comprised thrombocytopenia in two (4.8%) patients and one case (2.4%) each of peripheral sensory neuropathy, ascites, dyspnea exertional, gamma−glutamyltransferase increased, stomatitis, appendicitis, blood alkaline phosphatase, blood bilirubin increased, hepatic failure, hypertensive encephalopathy, hyperuricaemia, hypokalaemia, infection, pleural effusion, pneumonia, subileus, thrombotic microangiopathy, urinary incontinence, and vesicocutaneous fistula. Multiple occurrences of the same adverse event in one individual counted only once with the highest grade.

Seventeen (40.5%) patients experienced G≥3 toxicities judged to be study drug-related. Table 3 summarizes severe AEs expected from the mode of action (MoA) of vanucizumab. Fourteen (33%) patients experienced G≥3 hypertension, particularly with weekly and higher vanucizumab doses. Eight of these patients had a history of preexisting arterial hypertension. Hypertension led to vanucizumab dose modification/interruption in three patients and vanucizumab discontinuation in one patient. Ten (24%) patients experienced hemorrhagic events. Eight events were nonserious and G1: epistaxis (three patients); hemoptysis (two patients); mouth hemorrhage, purpura, and melena (one patient each). The other two events were SAEs, study drug-related, and led to vanucizumab discontinuation: G5 hemoptysis (19 mg/kg biweekly; described above) and G2 cerebral hemorrhage (30 mg/kg weekly). Five patients (11.9%) experienced proteinuria: 1 G3 (12 mg/kg biweekly) and 4 G1/2. Edema occurred in 5 (11.9%) patients (all G1/2).

Table 3.

Adverse events of special interest grade ≥ 3 (regardless of relationship)

Adverse event,Biweekly dosingWeekly dosing
n (%) MedDRA preferred term3 mg/kg (n = 1)6 mg/kg (n = 3)12 mg/kg (n = 4)19 mg/kg (n = 8)30 mg/kg (n = 6)Total (n = 22)10 mg/kg (n = 4)20 mg/kg (n = 4)30 mg/kg (n = 12)Total (n = 20)
Hypertension — — — — 4 (66.7) 4 (18.2) 1 (25.0) 1 (25.0) 8 (66.7) 10 (50.0) 
Thrombocytopenia — — — 1 (12.5) — 1 (4.5) — — 1 (8.3) 1 (5.0) 
Proteinuria — — 1 (25.0) — — 1 (4.5) — — — — 
Hemoptysis — — — 1 (12.5)a — 1 (4.5) — — — — 
Vesicocutaneous fistula — — 1 (25.0) — — 1 (4.5) — — — — 
Hypertensive encephalopathy — — — — — — — — 1 (8.3) 1 (5.0) 
Thrombotic microangiopathy — — — — — — — — 1 (8.3) 1 (5.0) 
Adverse event,Biweekly dosingWeekly dosing
n (%) MedDRA preferred term3 mg/kg (n = 1)6 mg/kg (n = 3)12 mg/kg (n = 4)19 mg/kg (n = 8)30 mg/kg (n = 6)Total (n = 22)10 mg/kg (n = 4)20 mg/kg (n = 4)30 mg/kg (n = 12)Total (n = 20)
Hypertension — — — — 4 (66.7) 4 (18.2) 1 (25.0) 1 (25.0) 8 (66.7) 10 (50.0) 
Thrombocytopenia — — — 1 (12.5) — 1 (4.5) — — 1 (8.3) 1 (5.0) 
Proteinuria — — 1 (25.0) — — 1 (4.5) — — — — 
Hemoptysis — — — 1 (12.5)a — 1 (4.5) — — — — 
Vesicocutaneous fistula — — 1 (25.0) — — 1 (4.5) — — — — 
Hypertensive encephalopathy — — — — — — — — 1 (8.3) 1 (5.0) 
Thrombotic microangiopathy — — — — — — — — 1 (8.3) 1 (5.0) 

Abbreviations: MedDRA, Medical Dictionary for Regulatory Activities. Multiple occurrences of the same AE in one individual are counted once.

aG5 adverse event.

Five patients had G1 AEs suggestive of an infusion-related reaction: influenza-like illness (3 patients) and hot flush and pruritus (1 patient each). Infusions were not interrupted or stopped in any of these patients.

Pharmacokinetics

Vanucizumab pharmacokinetic profiles are shown in Fig. 1A and descriptive statistics for the parameters are provided in Supplementary Tables S2 and S3. Cmax and AUC0–τ increased dose proportionally for both schedules with low inter-individual variability (<43%). Across the doses and schedules investigated, the volume of distribution of vanucizumab ranged from 2.9 to 6.1 L, plasma clearance was similar (range 10.9–36.7 mL/h), and t1/2 remained stable (range 6–9 days). Greater accumulation occurred with weekly dosing [accumulation ratios: 2.6-fold (Cmin), 2.1-fold (AUC0–τ)] than with biweekly dosing [1.9-fold (Cmin), 1.7-fold (AUC0–τ)].

Figure 1.

Pharmacokinetics of vanucizumab. A, Plasma concentration–time course (mean ± SD) of vanucizumab on cycles 1 and 4 following a biweekly (q2w) or weekly (qw) schedule at doses of 3 mg/kg to 30 mg/kg. B, Observed and model predicted vanucizumab concentrations after multiple administrations of vanucizumab 30 mg/kg biweekly or weekly. Circles/diamonds indicate observed values, solid lines indicate median predicted values, and shaded regions are the 95% predicted intervals. Red and green dotted lines indicates the Ctrough levels for bevacizumab 5 mg/kg biweekly and 10 mg/kg biweekly, respectively. C, Model predicted vanucizumab concentrations after multiple administrations of vanucizumab 30 mg/kg biweekly or 2,000 mg biweekly (solid lines indicate medians, and shaded regions are the 95% predicted intervals).

Figure 1.

Pharmacokinetics of vanucizumab. A, Plasma concentration–time course (mean ± SD) of vanucizumab on cycles 1 and 4 following a biweekly (q2w) or weekly (qw) schedule at doses of 3 mg/kg to 30 mg/kg. B, Observed and model predicted vanucizumab concentrations after multiple administrations of vanucizumab 30 mg/kg biweekly or weekly. Circles/diamonds indicate observed values, solid lines indicate median predicted values, and shaded regions are the 95% predicted intervals. Red and green dotted lines indicates the Ctrough levels for bevacizumab 5 mg/kg biweekly and 10 mg/kg biweekly, respectively. C, Model predicted vanucizumab concentrations after multiple administrations of vanucizumab 30 mg/kg biweekly or 2,000 mg biweekly (solid lines indicate medians, and shaded regions are the 95% predicted intervals).

Close modal

Population pharmacokinetic modeling indicated that Ctrough and Cavg vanucizumab concentrations comparable with those seen with 5 and 10 mg/kg bevacizumab (biweekly) would occur in 95% and 50%, respectively, of patients treated with 30 mg/kg biweekly vanucizumab by C2 (Fig. 1B). Simulations adjusted for an average 70 kg body weight predicted that a 2,000 mg biweekly flat dose would achieve similar vanucizumab exposure and peak/trough concentrations as 30 mg/kg biweekly dosing (Fig. 1C).

Two (5%) patients developed ADA following vanucizumab treatment (one after four cycles of 10 mg/kg weekly and one after 12 cycles of 30 mg/kg weekly); both without associated clinical symptoms or change in vanucizumab exposure. Accordingly, the ADA appeared to be non-neutralizing. Two patients had preexisting ADA.

Pharmacodynamics

The median baseline total plasma Ang-2 level was 2.5 ng/mL (range: 1.6–9.3 ng/mL) without apparent differences across tumor types. As expected, plasma levels of free VEGF-A and Ang-2 were depleted within 24 hours of administration, independent of dose and schedule (Fig. 2A and B). Conversely, total VEGF-A and Ang-2 levels increased upon first dose of vanucizumab.

Figure 2.

Pharmacodynamics of vanucizumab. Scatterplots depicting mean changes from baseline (± SEM) plasma levels of free (A and B) and total (C and D) VEGF-A and Ang-2. There were overall no significant differences across dosing cohorts and administration schedules. The single patient within the 19 mg/kg group is considered an outlier. E, AUCBN was measured by DCE-MRI.

Figure 2.

Pharmacodynamics of vanucizumab. Scatterplots depicting mean changes from baseline (± SEM) plasma levels of free (A and B) and total (C and D) VEGF-A and Ang-2. There were overall no significant differences across dosing cohorts and administration schedules. The single patient within the 19 mg/kg group is considered an outlier. E, AUCBN was measured by DCE-MRI.

Close modal

MRI was conducted in 34 patients, including 29 and 25 patients, respectively, with two baseline DCE-MRI and DW-MRI scans. The median baseline coefficient of variability was 20% for KTRANS, 9.0% for AUCBN, and 11.2% for ADC. Twenty-two (64.7%) patients had moderate-to-significant sustained posttreatment reductions in DCE-MRI parameters reflecting changes in vascular permeability, leakiness, and perfusion. Patients were grouped as either weekly or biweekly ≤20 mg/kg and 30 mg/kg. At C2D1, percent decrease from baseline in median KTRANS for ≤20 mg/kg biweekly was lower than ≤20 mg/kg weekly (–0.79 ±9.68 vs. −24.06 ±14.56), while for 30 mg/kg biweekly and 30 mg/kg weekly, the percent decrease from baseline in median KTRANS was similar (−31.37% ± 15.68 vs. −29.74% ± 6.53; Fig. 2E). A trend toward sustained decreases in vessel permeability and leakiness was observed in weekly patients and biweekly patients treated with 30 mg/kg (Fig. 2E). Supplementary Figure S1 shows parametric KTRANS map MRI images illustrating changes in vascular permeability for a colorectal cancer patient treated with 30 mg/kg biweekly. The median ADC for the 25 evaluable patients ranged from 769 to 4,805 μm/s. Seven (28%) patients had a >20% increase in posttreatment necrosis; six of whom were treated at 30 mg/kg (weekly or biweekly).

Clinical activity

Thirty-eight patients were evaluable for tumor response: Two had confirmed partial responses (PR), one had unconfirmed PR, 19 had stable disease, and 16 had progressive disease (Fig. 3). A 65-year-old male with metastatic colon cancer who switched from 30 mg/kg weekly to biweekly dosing after 6 months achieved a confirmed PR after one year of treatment. A 68-year-old male with metastatic renal cell cancer also exposed to 30 mg/kg biweekly had a confirmed PR upon 20 months of treatment and meanwhile remains on study for more than 3 years. A 48-year-old female with cervical cancer achieved a PR after six cycles of 30 mg/kg weekly, but discontinued the study due to brain hemorrhage before a confirmatory scan was available.

Figure 3.

Waterfall plot of best percentage change from baseline in the sum of the target lesions for patients treated biweekly (A) or weekly (B).The figure also shows the dose cohort. # Renal cell cancer patient with PR after approximately 20 months on treatment. *, Colon cancer patient who switched from weekly to biweekly dosing after 6 months and achieved a confirmed PR after approximately one year. ¶, Cervical cancer patient who achieved PR after six cycles and discontinued the study due to the AE of brain hemorrhage; therefore, no confirmatory scan was available. ‡, Patient had SD as the absolute increase from nadir was <5 mm.

Figure 3.

Waterfall plot of best percentage change from baseline in the sum of the target lesions for patients treated biweekly (A) or weekly (B).The figure also shows the dose cohort. # Renal cell cancer patient with PR after approximately 20 months on treatment. *, Colon cancer patient who switched from weekly to biweekly dosing after 6 months and achieved a confirmed PR after approximately one year. ¶, Cervical cancer patient who achieved PR after six cycles and discontinued the study due to the AE of brain hemorrhage; therefore, no confirmatory scan was available. ‡, Patient had SD as the absolute increase from nadir was <5 mm.

Close modal

Eleven (55%) and 8 (44%) patients on the biweekly and weekly schedules, respectively, had reductions in the sum of target lesions at least once during the study. At the first 8-week tumor assessment, 13 (65%) and 9 (50%) evaluable patients on the biweekly and weekly schedules, respectively, had not progressed. Overall, 10 patients were without disease progression for at least 6 months.

In this phase I study, vanucizumab, an investigational, first-in-class, bispecific Ang-2 and VEGF-A inhibitor, had an acceptable safety and tolerability profile in adult patients with advanced cancer consistent with that seen with bevacizumab and selective inhibitors of the Ang/Tie2 axis. Of note, the bispecific antibody generated using CrossMAb technology did not have a higher immunogenic potential compared with conventional antibody formats. One patient died due to pulmonary bleeding from a large centrally located mediastinal mass; this event was the only vanucizumab-related DLT. A MTD was not reached at the highest dose administered (30 mg/kg weekly /biweekly). Arterial hypertension was the most common G3/4 AE of vanucizumab, with an overall incidence of almost 60% (G≥3: 33%) and which was higher than previously reported for other single-agent inhibitors of the VEGF-A or Ang/Tie2 axis. Hypertension was generally asymptomatic and easily controlled. High blood pressure appeared to be dose dependent and predominantly driven by the systemic vanucizumab-mediated VEGF-A inhibition. Across clinical studies, the frequency of G3/4 hypertension is 9%–32% with bevacizumab monotherapy (21–25) but ≤6% for single-agent Ang-1/2 antagonists (26–33). Moreover, hypertension rates with bevacizumab treatment did not increase by concurrent inhibition of the Ang/Tie-2 signaling pathway in patients with metastatic breast cancer [39%–40% (G≥3: 18%–23%) compared with 38% (G≥3: 19%) without concurrent Ang/Tie-2 inhibition; ref. 33)].

Ang-2 and VEGF may be involved in promoting the integrity of glomerular endothelia (34–36). Altered glomerular permeability with leakage of large proteins into the urine appears to be a direct result of VEGF-A and Ang-2 inhibition. Proteinuria is a common side effect of bevacizumab with an overall incidence (all grades) of 20% (37) and has been reported in 14% of patients treated with agents targeting the Ang/Tie2 pathway (28). Simultaneous inhibition of VEGF-A and Ang-2 with vanucizumab did not increase the rate or grade of proteinuria. Although the exact mechanism by which edema might occur is unclear, dual, nonselective Ang-1 and Ang-2 inhibition frequently induces edema formation in up to 30% of patients (27, 28). In preclinical models, Ang-1 acts as an antipermeability factor and protects adult vessels from leaking (38). We observed mild-to-moderate peripheral edema in 12% of our patients treated with the Ang-2–selective CrossMAb, thereby suggesting a mostly anti-Ang-1–mediated adverse effect.

Vanucizumab demonstrated a favorable pharmacokinetic profile. The elimination t1/2 (6–9 days) was shorter than that of a typical IgG molecule. A low volume of distribution (2.9–6.1 L), consistent with other therapeutic mAbs (3–5 L; ref. 39), indicates that most of the drug was likely confined within the central compartment. Population pharmacokinetic simulations suggested that Ctrough and Cavg levels after biweekly dosing of 30 mg/kg vanucizumab will result in serum exposures comparable with the clinically established bevacizumab dosages of 5–10 mg/kg biweekly. A flat dose of 2,000 mg vanucizumab biweekly was also predicted to achieve similar exposure as 30 mg/kg biweekly. Dosing every other week supports patient convenience and combination with other systemic anticancer therapies administered at this interval. Fixed dosing offers considerable advantages in ease of dose preparation, reduced potential of dose calculation errors, and lower costs (40).

Circulating VEGF-A and Ang-2 kinetics provided further evidence of the biologic effects of vanucizumab on angiogenic pathways. Consistent with the postulated MoA, drug-unbound (free) levels of both biomarkers decreased rapidly following treatment. Free circulating VEGF concentrations were also reduced upon treatment with bevacizumab in previous clinical trials (41–45). The paradoxical increases of total VEGF-A and total Ang-2 across all dose groups were likely due to the prolonged t1/2 of vanucizumab-bound (inactive) targets and de novo synthesis of the ligands (43). The increase of total Ang-2 might also have been caused by the release of Ang-2 from Weibel–Palade–Bodies following vanucizumab treatment (46).

DCE-MRI serves as a pharmacodynamic marker of biological activity for antiangiogenic cancer drugs by providing information about tumor microvessel structure and function, thereby helping to define the biologically active dose (47). DW-MRI provides complementary information about cellularity and necrosis within tumor tissue (48). Vanucizumab induced the anticipated effects on tumor perfusion and reduced vascular permeability in most patients and across a variety of tumor types. Notably, we observed a sustained decrease in tumor vessel permeability (measured by KTRANS) and an increase in necrosis (measured as ADC) consistently with 30 mg/kg dosing in both schedules; the magnitude of reductions in KTRANS was similar to those occurring with agents targeting the VEGF pathway (49, 50).

Vanucizumab also showed encouraging signs of antitumor activity in this heterogeneous population of patients with advanced solid tumors refractory to available therapy. Although overall three patients treated at the highest dose level achieved PR, there was no clear trend suggesting a relationship between the dose and schedule of vanucizumab and the regression of tumors. Likewise, although limited by the small sample size and number of responders, there was no apparent relationship between baseline circulating Ang-2 levels and response.

In summary, the VEGF-A and angiopoietin signaling pathways represent attractive targets for cancer therapy. Vanucizumab simultaneously blocks VEGF-A and Ang-2 from interacting with their receptors and demonstrated an acceptable safety profile and evidence of antitumor effect at intravenous doses of up to 30 mg/kg biweekly. Clinical evaluations of vanucizumab combined with standard chemotherapy or novel cancer immunotherapies are in progress.

J. Albanell reports receiving speakers bureau honoraria from and is a consultant/advisory board member for Roche. T. Nayak has ownership interests (including patents) at F. Hoffman La Roche. O. Krieter has ownership interests (including patents) at Roche. No potential conflicts of interest were disclosed by the other authors.

Conception and design: M. Hidalgo, C. Massard, R. Bahleda, A. Lahr, K. Lechner, T. Nayak, K. Stubenrauch, O. Krieter

Development of methodology: M. Hidalgo, C. Massard, R. Bahleda, I. Franjkovic, K. Lechner, K. Stubenrauch, O. Krieter

Acquisition of data (provided animals, acquired and managed patients, provided facilities, etc.): M. Hidalgo, M. Martinez-Garcia, C. Le Tourneau, C. Massard, E. Garralda, V. Boni, A. Taus, J. Albanell, M.-P. Sablin, R. Bahleda, F. Heil, K. Lechner, A. Morel

Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis): M. Hidalgo, M. Martinez-Garcia, C. Le Tourneau, E. Garralda, V. Boni, R. Bahleda, C. Boetsch, F. Heil, A. Lahr, K. Lechner, T. Nayak, S. Rossomanno, K. Smart, K. Stubenrauch, O. Krieter

Writing, review, and/or revision of the manuscript: M. Hidalgo, M. Martinez-Garcia, C. Le Tourneau, C. Massard, E. Garralda, V. Boni, A. Taus, J. Albanell, M.-P. Sablin, M. Alt, R. Bahleda, A. Varga, C. Boetsch, I. Franjkovic, F. Heil, A. Lahr, K. Lechner, A. Morel, T. Nayak, S. Rossomanno, K. Smart, K. Stubenrauch, O. Krieter

Administrative, technical, or material support (i.e., reporting or organizing data, constructing databases): E. Garralda, I. Franjkovic, A. Morel, O. Krieter

Study supervision: M. Hidalgo, C. Massard, E. Garralda, J. Albanell, C. Boetsch, A. Lahr, A. Morel

We thank the patients and their families for their participation in this study and the staff at the study sites. This study and editorial support for the preparation of this manuscript were funded by F. Hoffmann-La Roche Ltd. Support for third-party writing assistance for this article, furnished by Jamie Ashman, PhD, was provided by Prism Ideas.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

1.
Folkman
J
. 
Angiogenesis: an organizing principle for drug discovery?
Nat Rev Drug Discov
2007
;
6
:
273
86
.
2.
Amit
L
,
Ben-Aharon
I
,
Vidal
L
,
Leibovici
L
,
Stemmer
S
. 
The impact of bevacizumab (Avastin) on survival in metastatic solid tumors: A meta-analysis and systematic review
.
PLoS One
2013
;
8
:
e51780
.
3.
Ellis
LM
,
Hicklin
DJ
. 
Pathways mediating resistance to vascular endothelial growth factor-targeted therapy
.
Clin Cancer Res
2008
;
14
:
6371
5
.
4.
Fiedler
U
,
Krissl
T
,
Koidl
S
,
Weiss
C
,
Koblizek
T
,
Deutsch
U
, et al
Angiopoietin-1 and angiopoietin-2 share the same binding domains in the Tie-2 receptor involving the first Ig-like loop and the epidermal growth factor-like repeats
.
J Biol Chem
2003
;
278
:
1721
7
.
5.
Maisonpierre
PC
,
Suri
C
,
Jones
PF
,
Bartunkova
S
,
Wiegand
SJ
,
Radziejewski
C
, et al
Angiopoietin-2, a natural antagonist for Tie2 that disrupts in vivo angiogenesis
.
Science
1997
;
277
:
55
60
.
6.
Tait
CR
,
Jones
PF
. 
Angiopoietins in tumours: the angiogenic switch
.
J Pathol
2004
;
204
:
1
10
.
7.
Tanaka
F
,
Ishikawa
S
,
Yanagihara
K
,
Miyahara
R
,
Kawano
Y
,
Li
M
, et al
Expression of angiopoietins and its clinical significance in non-small cell lung cancer
.
Cancer Res
2002
;
62
:
7124
9
.
8.
Tsutsui
S
,
Inoue
H
,
Yasuda
K
,
Suzuki
K
,
Takeuchi
H
,
Nishizaki
T
, et al
Angiopoietin 2 expression in invasive ductal carcinoma of the breast: Its relationship to the VEGF expression and microvessel density
.
Breast Cancer Res Treat
2006
;
98
:
261
6
.
9.
Sallinen
H
,
Heikura
T
,
Koponen
J
,
Kosma
VM
,
Heinonen
S
,
Yla-Herttuala
S
, et al
Serum angiopoietin-2 and soluble VEGFR-2 levels predict malignancy of ovarian neoplasm and poor prognosis in epithelial ovarian cancer
.
BMC Cancer
2014
;
14
:
696
.
10.
Li
P
,
He
Q
,
Luo
C
,
Qian
L
. 
Diagnostic and prognostic potential of serum angiopoietin-2 expression in human breast cancer
.
Int J Clin Exp Pathol
2015
;
8
:
660
4
.
11.
Goede
V
,
Coutelle
O
,
Neuneier
J
,
Reinacher-Schick
A
,
Schnell
R
,
Koslowsky
TC
, et al
Identification of serum angiopoietin-2 as a biomarker for clinical outcome of colorectal cancer patients treated with bevacizumab-containing therapy
.
Br J Cancer
2010
;
103
:
1407
14
.
12.
Kim
S
,
Dobi
E
,
Jary
M
,
Monnien
F
,
Curtit
E
,
Nguyen
T
, et al
Bifractionated CPT-11 with LV5FU2 infusion (FOLFIRI-3) in combination with bevacizumab: Clinical outcomes in first-line metastatic colorectal cancers according to plasma angiopoietin-2 levels
.
BMC Cancer
2013
;
13
:
611
.
13.
Motzer
RJ
,
Hutson
TE
,
Hudes
GR
,
Figlin
RA
,
Martini
JF
,
English
PA
, et al
Investigation of novel circulating proteins, germ line single-nucleotide polymorphisms, and molecular tumor markers as potential efficacy biomarkers of first-line sunitinib therapy for advanced renal cell carcinoma
.
Cancer Chemother Pharmacol
2014
;
74
:
739
50
.
14.
Yoshiji
H
,
Kuriyama
S
,
Noguchi
R
,
Yoshii
J
,
Ikenaka
Y
,
Yanase
K
, et al
Angiopoietin 2 displays a vascular endothelial growth factor dependent synergistic effect in hepatocellular carcinoma development in mice
.
Gut
2005
;
54
:
1768
75
.
15.
Weidner
N
,
Carroll
PR
,
Flax
J
,
Blumenfeld
W
,
Folkman
J
. 
Tumor angiogenesis correlates with metastasis in invasive prostate carcinoma
.
Am J Pathol
1993
;
143
:
401
9
.
16.
Andersen
S
,
Donnem
T
,
Al-Shibli
K
,
Al-Saad
S
,
Stenvold
H
,
Busund
LT
, et al
Prognostic impacts of angiopoietins in NSCLC tumor cells and stroma: VEGF-A impact is strongly associated with Ang-2
.
PLoS One
2011
;
6
:
e19773
.
17.
Schaefer
W
,
Regula
JT
,
Bahner
M
,
Schanzer
J
,
Croasdale
R
,
Durr
H
, et al
Immunoglobulin domain crossover as a generic approach for the production of bispecific IgG antibodies
.
Proc Natl Acad Sci U S A
2011
;
108
:
11187
92
.
18.
Kienast
Y
,
Klein
C
,
Scheuer
W
,
Raemsch
R
,
Lorenzon
E
,
Bernicke
D
, et al
Ang-2-VEGF-A CrossMab, a novel bispecific human IgG1 antibody blocking VEGF-A and Ang-2 functions simultaneously, mediates potent antitumor, antiangiogenic, and antimetastatic efficacy
.
Clin Cancer Res
2013
;
19
:
6730
40
.
19.
Babb
J
,
Rogatko
A
,
Zacks
S
. 
Cancer phase I clinical trials: efficient dose escalation with overdose control
.
Stat Med
1998
;
17
:
1103
20
.
20.
Bailey
S
,
Neuenschwander
B
. 
Bayesian model-based approaches for single and combination dose finding
.
American Statistical Association Webinar
.
Available from:
http://www.amstat.org/education/learnstat/index.cfm.
21.
Ogita
S
,
Tejwani
S
,
Heilbrun
L
,
Fontana
J
,
Heath
E
,
Freeman
S
, et al
Pilot Phase II trial of bevacizumab monotherapy in nonmetastatic castrate-resistant prostate cancer
.
ISRN Oncol
2012
;
2012
:
242850
.
22.
Kreisl
TN
,
Zhang
W
,
Odia
Y
,
Shih
JH
,
Butman
JA
,
Hammoud
D
, et al
A phase II trial of single-agent bevacizumab in patients with recurrent anaplastic glioma
.
Neuro Oncol
2011
;
13
:
1143
50
.
23.
Cannistra
SA
,
Matulonis
UA
,
Penson
RT
,
Hambleton
J
,
Dupont
J
,
Mackey
H
, et al
Phase II study of bevacizumab in patients with platinum-resistant ovarian cancer or peritoneal serous cancer
.
J Clin Oncol
2007
;
25
:
5180
6
.
24.
Burger
RA
,
Sill
MW
,
Monk
BJ
,
Greer
BE
,
Sorosky
JI
. 
Phase II trial of bevacizumab in persistent or recurrent epithelial ovarian cancer or primary peritoneal cancer: a gynecologic oncology group study
.
J Clin Oncol
2007
;
25
:
5165
71
.
25.
Cobleigh
MA
,
Langmuir
VK
,
Sledge
GW
,
Miller
KD
,
Haney
L
,
Novotny
WF
, et al
A phase I/II dose-escalation trial of bevacizumab in previously treated metastatic breast cancer
.
Semin Oncol
2003
;
30
:
117
24
.
26.
Hyman
DM
,
Rizvi
NA
,
Natale
RB
,
Armstrong
DK
,
Birrer
MJ
,
Recht
LD
, et al
A phase 1 study of MEDI3617, a selective angiopoietin-2 inhibitor, alone and in combination with carboplatin/paclitaxel, paclitaxel, or bevacizumab in patients with advanced solid tumors
.
J Clin Oncol
2014
;
32
:
abstract 3012
.
27.
Herbst
RS
,
Hong
D
,
Chap
L
,
Kurzrock
R
,
Jackson
E
,
Silverman
JM
, et al
Safety, pharmacokinetics, and antitumor activity of AMG 386, a selective angiopoietin inhibitor, in adult patients with advanced solid tumors
.
J Clin Oncol
2009
;
27
:
3557
65
.
28.
Dowlati
A
,
Vlahovic
G
,
Natale
RB
,
Rasmussen
E
,
Singh
I
,
Hwang
YC
, et al
A Phase I, first-in-human study of AMG 780, an angiopoietin-1 and -2 inhibitor, in patients with advanced solid tumors
.
Clin Cancer Res
2016
;
22
:
4574
84
.
29.
Doi
T
,
Ohtsu
A
,
Fuse
N
,
Yoshino
T
,
Tahara
M
,
Shibayama
K
, et al
Phase 1 study of trebananib (AMG 386), an angiogenesis targeting angiopoietin-1/2 antagonist, in Japanese patients with advanced solid tumors
.
Cancer Chemother Pharmacol
2013
;
71
:
227
35
.
30.
Hayman
SR
,
Leung
N
,
Grande
JP
,
Garovic
VD
. 
VEGF inhibition, hypertension, and renal toxicity
.
Curr Oncol Rep
2012
;
14
:
285
94
.
31.
Papadopoulos
KP
,
Kelley
RK
,
Tolcher
AW
,
Razak
AR
,
Van
LK
,
Patnaik
A
, et al
A Phase I first-in-human study of nesvacumab (REGN910), a fully human anti-angiopoietin-2 (Ang2) monoclonal antibody, in patients with advanced solid tumors
.
Clin Cancer Res
2016
;
22
:
1348
55
.
32.
Rosen
LS
,
Mendelson
DS
,
Cohen
RB
,
Gordon
MS
,
Goldman
JW
,
Bear
IK
, et al
First-in-human dose-escalation safety and PK trial of a novel intravenous humanized monoclonal CovX body inhibiting angiopoietin 2
.
J Clin Oncol
2010
;
28
:
15
.
33.
Dieras
V
,
Wildiers
H
,
Jassem
J
,
Dirix
LY
,
Guastalla
JP
,
Bono
P
, et al
Trebananib (AMG 386) plus weekly paclitaxel with or without bevacizumab as first-line therapy for HER2-negative locally recurrent or metastatic breast cancer: a phase 2 randomized study
.
The Breast
2015
;
24
:
182
90
.
34.
de Caestecker
MP
. 
Angiopoietin-2 and glomerular proteinuria
.
J Am Soc Nephrol
2007
;
18
:
2217
8
.
35.
Lee
CS
,
Alwan
LM
,
Sun
X
,
McLean
KA
,
Urban
RR
. 
Routine proteinuria monitoring for bevacizumab in patients with gynecologic malignancies
.
J Oncol Pharm Pract
2016
;
22
:
771
6
.
36.
Woolf
AS
,
Gnudi
L
,
Long
DA
. 
Roles of angiopoietins in kidney development and disease
.
J Am Soc Nephrol
2009
;
20
:
239
44
.
37.
Roche Registration Limited
.
Avastin(R) (bevacizumab) Summary of product characteristics
.
Available from:
http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000582/WC500029271.pdf.
38.
Thurston
G
,
Rudge
JS
,
Ioffe
E
,
Zhou
H
,
Ross
L
,
Croll
SD
, et al
Angiopoietin-1 protects the adult vasculature against plasma leakage
.
Nat Med
2000
;
6
:
460
3
.
39.
Leveque
D
,
Wisniewski
S
,
Jehl
F
. 
Pharmacokinetics of therapeutic monoclonal antibodies used in oncology
.
Anticancer Res
2005
;
25
:
2327
43
.
40.
Mathijssen
RH
,
de Jong
FA
,
Loos
WJ
,
van der Bol
JM
,
Verweij
J
,
Sparreboom
A
. 
Flat-fixed dosing versus body surface area based dosing of anticancer drugs in adults: does it make a difference?
Oncologist
2007
;
12
:
913
23
.
41.
Azzariti
A
,
Porcelli
L
,
Brunetti
O
,
Del
RM
,
Longo
V
,
Nardulli
P
, et al
Total and not bevacizumab-bound vascular endothelial growth factor as potential predictive factors to bevacizumab-based chemotherapy in colorectal cancer
.
World J Gastroenterol
2016
;
22
:
6287
95
.
42.
Brostjan
C
,
Gebhardt
K
,
Gruenberger
B
,
Steinrueck
V
,
Zommer
H
,
Freudenthaler
H
, et al
Neoadjuvant treatment of colorectal cancer with bevacizumab: the perioperative angiogenic balance is sensitive to systemic thrombospondin-1 levels
.
Clin Cancer Res
2008
;
14
:
2065
74
.
43.
Gordon
MS
,
Margolin
K
,
Talpaz
M
,
Sledge
GW
 Jr.
,
Holmgren
E
,
Benjamin
R
, et al
Phase I safety and pharmacokinetic study of recombinant human anti-vascular endothelial growth factor in patients with advanced cancer
.
J Clin Oncol
2001
;
19
:
843
50
.
44.
Loupakis
F
,
Falcone
A
,
Masi
G
,
Fioravanti
A
,
Kerbel
RS
,
Del
TM
, et al
Vascular endothelial growth factor levels in immunodepleted plasma of cancer patients as a possible pharmacodynamic marker for bevacizumab activity
.
J Clin Oncol
2007
;
25
:
1816
8
.
45.
Keskin
M
,
Ustuner
Z
,
Dincer
M
,
Etiz
D
,
Gelik
HE
,
Gulbas
Z
. 
Importance of serum VEGF and basic FGF levels in determining response to treatment and survival in patients with metastatic colorectal cancer
.
J Clin Oncol
2012
;
30
:
abstract e21050
.
46.
Rondaij
MG
,
Bierings
R
,
Kragt
A
,
van Mourik
JA
,
Voorberg
J
. 
Dynamics and plasticity of Weibel-Palade bodies in endothelial cells
.
Arterioscler Thromb Vasc Biol
2006
;
26
:
1002
7
.
47.
Padhani
AR
,
Leach
MO
. 
Antivascular cancer treatments: functional assessments by dynamic contrast-enhanced magnetic resonance imaging
.
Abdom Imaging
2005
;
30
:
324
41
.
48.
Pope
WB
,
Kim
HJ
,
Huo
J
,
Alger
J
,
Brown
MS
,
Gjertson
D
, et al
Recurrent glioblastoma multiforme: ADC histogram analysis predicts response to bevacizumab treatment
.
Radiology
2009
;
252
:
182
9
.
49.
Hirashima
Y
,
Yamada
Y
,
Tateishi
U
,
Kato
K
,
Miyake
M
,
Horita
Y
, et al
Pharmacokinetic parameters from 3-Tesla DCE-MRI as surrogate biomarkers of antitumor effects of bevacizumab plus FOLFIRI in colorectal cancer with liver metastasis
.
Int J Cancer
2012
;
130
:
2359
65
.
50.
O'Connor
JP
,
Carano
RA
,
Clamp
AR
,
Ross
J
,
Ho
CC
,
Jackson
A
, et al
Quantifying antivascular effects of monoclonal antibodies to vascular endothelial growth factor: insights from imaging
.
Clin Cancer Res
2009
;
15
:
6674
82
.