Search

Supplementary Figures 1-4 from Preclinical Pharmacology, Antitumor Activity, and Development of Pharmacodynamic Markers for the Novel, Potent AKT Inhibitor CCT128930

Supplementary Figure Legends and Supplementary Table 1 from Preclinical Pharmacology, Antitumor Activity, and Development of Pharmacodynamic Markers for the Novel, Potent AKT Inhibitor CCT128930

AKT is frequently deregulated in cancer, making it an attractive anticancer drug target. CCT128930 is a novel ATP-competitive AKT inhibitor discovered using fragment- and structure-based approaches. It is a potent, advanced lead pyrrolopyrimidine compound exhibiting selectivity for AKT over PKA, achieved by targeting a single amino acid difference. CCT128930 exhibited marked antiproliferative activity and inhibited the phosphorylation of a range of AKT substrates in multiple tumor cell lines in vitro, consistent with AKT inhibition. CCT128930 caused a G1 arrest in PTEN-null U87MG human glioblastoma cells, consistent with AKT pathway blockade. Pharmacokinetic studies established that potentially active concentrations of CCT128930 could be achieved in human tumor xenografts. Furthermore, CCT128930 also blocked the phosphorylation of several downstream AKT biomarkers in U87MG tumor xenografts, indicating AKT inhibition in vivo. Antitumor activity was observed with CCT128930 in U87MG and HER2-positive, PIK3CA-mutant BT474 human breast cancer xenografts, consistent with its pharmacokinetic and pharmacodynamic properties. A quantitative immunofluorescence assay to measure the phosphorylation and total protein expression of the AKT substrate PRAS40 in hair follicles is presented. Significant decreases in pThr246 PRAS40 occurred in CCT128930-treated mouse whisker follicles in vivo and human hair follicles treated ex vivo, with minimal changes in total PRAS40. In conclusion, CCT128930 is a novel, selective, and potent AKT inhibitor that blocks AKT activity in vitro and in vivo and induces marked antitumor responses. We have also developed a novel biomarker assay for the inhibition of AKT in human hair follicles, which is currently being used in clinical trials. Mol Cancer Ther; 10(2); 360–71. ©2010 AACR.

Purpose: Multiple cancers harbor genetic aberrations that impact AKT signaling. MK-2206 is a potent pan-AKT inhibitor with a maximum tolerated dose (MTD) previously established at 60 mg on alternate days (QOD). Due to a long half-life (60–80 hours), a weekly (QW) MK-2206 schedule was pursued to compare intermittent QW and continuous QOD dosing.Experimental Design: Patients with advanced cancers were enrolled in a QW dose-escalation phase I study to investigate the safety and pharmacokinetic–pharmacodynamic profiles of tumor and platelet-rich plasma (PRP). The QOD MTD of MK-2206 was also assessed in patients with ovarian and castration-resistant prostate cancers and patients with advanced cancers undergoing multiparametric functional magnetic resonance imaging (MRI) studies, including dynamic contrast-enhanced MRI, diffusion-weighted imaging, magnetic resonance spectroscopy, and intrinsic susceptibility-weighted MRI.Results: A total of 71 patients were enrolled; 38 patients had 60 mg MK-2206 QOD, whereas 33 received MK-2206 at 90, 135, 150, 200, 250, and 300 mg QW. The QW MK-2206 MTD was established at 200 mg following dose-limiting rash at 250 and 300 mg. QW dosing appeared to be similarly tolerated to QOD, with toxicities including rash, gastrointestinal symptoms, fatigue, and hyperglycemia. Significant AKT pathway blockade was observed with both continuous QOD and intermittent QW dosing of MK-2206 in serially obtained tumor and PRP specimens. The functional imaging studies demonstrated that complex multiparametric MRI protocols may be effectively implemented in a phase I trial.Conclusions: Treatment with MK-2206 safely results in significant AKT pathway blockade in QOD and QW schedules. The intermittent dose of 200 mg QW is currently used in phase II MK-2206 monotherapy and combination studies (NCT00670488). Clin Cancer Res; 20(22); 5672–85. ©2014 AACR.

PDF file - 81K, Supplementary data comprising the materials and methods for (i) crystallography (ii) gene expression studies (iii) siRNA studies and Supplementary Figure legends 1-7

XLS file - 703K, Gene expression data for CCT128930: Genes that showed at least a 1.5 Fold Change in at least one treated sample compared to vehicle control and were differentially expressed between the treatment groups (Welch ANOVA FDR5%)

Sup Figure 3. A 59-year-old male with metastatic colorectal cancer treated with 60mg QOD of MK-2206.

Sup Figure 2. Box-and-whisker plots showing that the extent of multiparametric MRI (DCE-MRI (A), DWI (B), 1H-MRS (C) and ISW-MRI (D)) parameter changes in patients on MK-2206

Sup Figure 4. A 42-year-old female with metastatic breast cancer treated with 60mg QOD of MK-2206.

Purpose: Deregulated phosphatidylinositol 3-kinase pathway signaling through AGC kinases including AKT, p70S6 kinase, PKA, SGK and Rho kinase is a key driver of multiple cancers. The simultaneous inhibition of multiple AGC kinases may increase antitumor activity and minimize clinical resistance compared with a single pathway component.Experimental Design: We investigated the detailed pharmacology and antitumor activity of the novel clinical drug candidate AT13148, an oral ATP-competitive multi-AGC kinase inhibitor. Gene expression microarray studies were undertaken to characterize the molecular mechanisms of action of AT13148.Results: AT13148 caused substantial blockade of AKT, p70S6K, PKA, ROCK, and SGK substrate phosphorylation and induced apoptosis in a concentration and time-dependent manner in cancer cells with clinically relevant genetic defects in vitro and in vivo. Antitumor efficacy in HER2-positive, PIK3CA-mutant BT474 breast, PTEN-deficient PC3 human prostate cancer, and PTEN-deficient MES-SA uterine tumor xenografts was shown. We show for the first time that induction of AKT phosphorylation at serine 473 by AT13148, as reported for other ATP-competitive inhibitors of AKT, is not a therapeutically relevant reactivation step. Gene expression studies showed that AT13148 has a predominant effect on apoptosis genes, whereas the selective AKT inhibitor CCT128930 modulates cell-cycle genes. Induction of upstream regulators including IRS2 and PIK3IP1 as a result of compensatory feedback loops was observed.Conclusions: The clinical candidate AT13148 is a novel oral multi-AGC kinase inhibitor with potent pharmacodynamic and antitumor activity, which shows a distinct mechanism of action from other AKT inhibitors. AT13148 will now be assessed in a first-in-human phase I trial. Clin Cancer Res; 18(14); 3912–23. ©2012 AACR.

XLS file - 66K, Genes that showed at least a 1.5 Fold Change in at least one treated sample compared to vehicle control and were differentially expressed between the treatment groups (Welch ANOVA FDR5%) for both CCT128930 and AT13148

Sup Figure 1. Mean plasma versus time profile for MK-2206 following 60mg QOD dosing for 27 Days in patients on the expansion cohorts

PDF file - 553K, Supplementary Figure 1. Phosphorylation of AKT substrates remains suppressed, despite pSer473 AKT induction. Supplementary Figure 2. The pharmacokinetic-pharmacodynamic profile and antitumor activity of AT13148 in PTEN-deficient PC3 human prostate cancer xenografts. Supplementary Figure 3. Pharmacodynamic biomarker study of AT13148(40mg/kg) in MES-SA human tumor xenografts. Supplementary Figure 4. The antitumour activity of AT13148 in mutant KRAS A549 human lung cancer xenografts. Supplementary Figure 5. Mouse body weight data for the MES-SA (Figure 4B) and BT474 (Figure 4C) efficacy studies. Supplementary Figure 6. The effect of AT13148 versus CCT128930 on apoptosis and cell cycle distribution in U87MG human glioblastoma cells. Supplementary Figure 7. Differential effects of 24h treatment of 10M each of the AGC kinase inhibitor AT13148 and the selective AKT inhibitor CCT128930 on cell cycle effects in PTEN-deficient U87MG human glioblastoma cells. Supplementary Table 1. Summary of the inhibitory activity of 10��M AT13148 against in vitro. Supplementary Table 2. Summary of the inhibitory activity of AT13148 against a panel of protein kinases Supplementary Table 3. Summary of the in vitro cytotoxicity of AT13148 against a panel of human tumor cell lines harboring different defects in the PI3K-AKT signaling pathway. Supplementary Table 4. Summary of the pharmacokinetics of AT13148 in mouse plasma and tissues following iv or oral administration

Purpose: Multiple cancers harbor genetic aberrations that impact AKT signaling. MK-2206 is a potent pan-AKT inhibitor with a maximum tolerated dose (MTD) previously established at 60 mg on alternate days (QOD). Due to a long half-life (60–80 hours), a weekly (QW) MK-2206 schedule was pursued to compare intermittent QW and continuous QOD dosing. Experimental Design: Patients with advanced cancers were enrolled in a QW dose-escalation phase I study to investigate the safety and pharmacokinetic–pharmacodynamic profiles of tumor and platelet-rich plasma (PRP). The QOD MTD of MK-2206 was also assessed in patients with ovarian and castration-resistant prostate cancers and patients with advanced cancers undergoing multiparametric functional magnetic resonance imaging (MRI) studies, including dynamic contrast-enhanced MRI, diffusion-weighted imaging, magnetic resonance spectroscopy, and intrinsic susceptibility-weighted MRI. Results: A total of 71 patients were enrolled; 38 patients had 60 mg MK-2206 QOD, whereas 33 received MK-2206 at 90, 135, 150, 200, 250, and 300 mg QW. The QW MK-2206 MTD was established at 200 mg following dose-limiting rash at 250 and 300 mg. QW dosing appeared to be similarly tolerated to QOD, with toxicities including rash, gastrointestinal symptoms, fatigue, and hyperglycemia. Significant AKT pathway blockade was observed with both continuous QOD and intermittent QW dosing of MK-2206 in serially obtained tumor and PRP specimens. The functional imaging studies demonstrated that complex multiparametric MRI protocols may be effectively implemented in a phase I trial. Conclusions: Treatment with MK-2206 safely results in significant AKT pathway blockade in QOD and QW schedules. The intermittent dose of 200 mg QW is currently used in phase II MK-2206 monotherapy and combination studies (NCT00670488). Clin Cancer Res; 20(22); 5672–85. ©2014 AACR.

Purpose: Deregulated phosphatidylinositol 3-kinase pathway signaling through AGC kinases including AKT, p70S6 kinase, PKA, SGK and Rho kinase is a key driver of multiple cancers. The simultaneous inhibition of multiple AGC kinases may increase antitumor activity and minimize clinical resistance compared with a single pathway component. Experimental Design: We investigated the detailed pharmacology and antitumor activity of the novel clinical drug candidate AT13148, an oral ATP-competitive multi-AGC kinase inhibitor. Gene expression microarray studies were undertaken to characterize the molecular mechanisms of action of AT13148. Results: AT13148 caused substantial blockade of AKT, p70S6K, PKA, ROCK, and SGK substrate phosphorylation and induced apoptosis in a concentration and time-dependent manner in cancer cells with clinically relevant genetic defects in vitro and in vivo. Antitumor efficacy in HER2-positive, PIK3CA-mutant BT474 breast, PTEN-deficient PC3 human prostate cancer, and PTEN-deficient MES-SA uterine tumor xenografts was shown. We show for the first time that induction of AKT phosphorylation at serine 473 by AT13148, as reported for other ATP-competitive inhibitors of AKT, is not a therapeutically relevant reactivation step. Gene expression studies showed that AT13148 has a predominant effect on apoptosis genes, whereas the selective AKT inhibitor CCT128930 modulates cell-cycle genes. Induction of upstream regulators including IRS2 and PIK3IP1 as a result of compensatory feedback loops was observed. Conclusions: The clinical candidate AT13148 is a novel oral multi-AGC kinase inhibitor with potent pharmacodynamic and antitumor activity, which shows a distinct mechanism of action from other AKT inhibitors. AT13148 will now be assessed in a first-in-human phase I trial. Clin Cancer Res; 18(14); 3912–23. ©2012 AACR.

Background: The Ras/RAF/MEK/ERK pathway is frequently deregulated in cancer and a number of inhibitors that target this pathway are currently in clinical development. It is likely that clinical testing of these agents will be in combination with standard therapies to harness the apoptotic potential of both the agents. To support this strategy, it has been widely observed that a number of chemotherapeutics stimulate the activation of several intracellular signalling cascades including Ras/RAF/MEK/ERK. The MEK1/2 inhibitor selumetinib has been shown to have anti-tumour activity and induce apoptotic cell death as a monotherapy. Methods: The aim of this study was to identify agents, which would be likely to offer clinical benefit when combined with selumetinib. Here, we used human tumour xenograft models and assessed the effects combining standard chemotherapeutic agents with selumetinib on tumour growth. In addition, we analysed tumour tissue to determine the mechanistic effects of these combinations. Results: Combining selumetinib with the DNA-alkylating agent, temozolomide (TMZ), resulted in enhanced tumour growth inhibition compared with monotherapies. Biomarker studies highlighted an increase in γH2A.X suggesting that selumetinib is able to enhance the DNA damage induced by TMZ alone. In several models we observed that continuous exposure to selumetinib in combination with docetaxel results in tumour regression. Scheduling of docetaxel before selumetinib was more beneficial than when selumetinib was dosed before docetaxel and demonstrated a pro-apoptotic phenotype. Similar results were seen when selumetinib was combined with the Aurora B inhibitor barasertib. Conclusion: The data presented suggests that MEK inhibition in combination with several standard chemotherapeutics or an Aurora B kinase inhibitor is a promising clinical strategy.

There is an urgent need for improved therapies for children with high-risk neuroblastoma\ud where survival rates remain low. MYCN amplification is the most common genomic change\ud associated with aggressive neuroblastoma and drugs targeting PI3K/AKT/mTOR, to activate\ud MYCNoncoprotein degradation, are entering clinical evaluation. Our aim was to develop and\ud validate pharmacodynamic (PD) biomarkers to evaluate both proof of mechanism and proof\ud of concept for drugs that block PI3K/AKT/mTOR pathway activity in children with neuroblastoma.\ud Wehave addressed the issue of limited access to tumor biopsies for quantitative detection\ud of protein biomarkers by optimizing a three-color fluorescence activated cell sorting\ud (FACS) method to purify CD45?/GD2+/CD56+ neuroblastoma cells from bone marrow. We\ud then developed a novel quantitative measurement of MYCN protein in these isolated neuroblastoma\ud cells, providing the potential to demonstrate proof of concept for drugs that inhibit\ud PI3K/AKT/mTOR signaling in this disease. In addition we have established quantitative\ud detection of three biomarkers for AKT pathway activity (phosphorylated and total AKT,\ud GSK3b and P70S6K) in surrogate platelet-rich plasma (PRP) frompediatric patients. Together\ud ournewapproachto neuroblastomacell isolation for protein detection and suite ofPD assays\ud provides for the first time the opportunity for robust, quantitative measurement of proteinbased\ud PD biomarkers in this pediatric patient population. These will be ideal tools to support\ud clinical evaluation of PI3K/AKT/mTOR pathway drugs and their ability to target MYCN oncoprotein\ud in upcoming clinical trials in neuroblastoma.

Topical TLR7 agonists such as imiquimod are highly effective for the treatment of dermatological malignancies; however, their efficacy in the treatment of nondermatological tumors has been less successful. We report that oral administration of the novel TLR7-selective small molecule agonist; SM-276001, leads to the induction of an inflammatory cytokine and chemokine milieu and to the activation of a diverse population of immune effector cells including T and B lymphocytes, NK and NKT cells. Oral administration of SM-276001 leads to the induction of IFNα, TNFα and IL-12p40 and a reduction in tumor burden in the Balb/c syngeneic Renca and CT26 models. Using the OV2944-HM-1 model of ovarian cancer which spontaneously metastasizes to the lungs following subcutaneous implantation, we evaluated the efficacy of intratracheal and oral administration of SM-276001 in an adjuvant setting following surgical resection of the primary tumor. We show that both oral and intratracheal TLR7 therapy can reduce the frequency of pulmonary metastasis, and metastasis to the axillary lymph nodes. These results demonstrate that SM-276001 is a potent selective TLR7 agonist that can induce antitumor immune responses when dosed either intratracheally or orally.

Purpose AKT signaling is frequently deregulated in human cancers. MK-2206 is a potent, oral allosteric inhibitor of all AKT isoforms with antitumor activity in preclinical models. A phase I study of MK-2206 was conducted to investigate its safety, maximum-tolerated dose (MTD), pharmacokinetics (PKs), pharmacodynamics (PDs), and preliminary antitumor efficacy. Patients and Methods Patients with advanced solid tumors received MK-2206 on alternate days. Paired tumor biopsies were mandated at the MTD for biomarker studies. PD studies incorporated tumor and hair follicle analyses, and putative predictive biomarker studies included tumor somatic mutation analyses and immunohistochemistry for phosphatase and tensin homolog (PTEN) loss. Results Thirty-three patients received MK-2206 at 30, 60, 75, or 90 mg on alternate days. Dose-limiting toxicities included skin rash and stomatitis, establishing the MTD at 60 mg. Drug-related toxicities included skin rash (51.5%), nausea (36.4%), pruritus (24.2%), hyperglycemia (21.2%), and diarrhea (21.2%). PKs (area under the concentration-time curve from 0 to 48 hours and maximum measured plasma concentration) were dose proportional. Phosphorylated serine 473 AKT declined in all tumor biopsies assessed (P = .015), and phosphorylated threonine 246 proline-rich AKT substrate 40 was suppressed in hair follicles at 6 hours (P = .008), on days 7 (P = .028) and 15 (P = .025) with MK-2206; reversible hyperglycemia and increases in insulin c-peptide were also observed, confirming target modulation. A patient with pancreatic adenocarcinoma (PTEN loss; KRAS G12D mutation) treated at 60 mg on alternate days experienced a decrease of approximately 60% in cancer antigen 19-9 levels and 23% shrinkage in tumor measurements. Two patients with pancreatic neuroendocrine tumors had minor tumor responses. Conclusion MK-2206 was well tolerated, with evidence of AKT signaling blockade. Rational combination trials are ongoing to maximize clinical benefit with this therapeutic strategy.

AKT is frequently deregulated in cancer, making it an attractive anticancer drug target. CCT128930 is a novel ATP-competitive AKT inhibitor discovered using fragment- and structure-based approaches. It is a potent, advanced lead pyrrolopyrimidine compound exhibiting selectivity for AKT over PKA, achieved by targeting a single amino acid difference. CCT128930 exhibited marked antiproliferative activity and inhibited the phosphorylation of a range of AKT substrates in multiple tumor cell lines in vitro, consistent with AKT inhibition. CCT128930 caused a G1 arrest in PTEN-null U87MG human glioblastoma cells, consistent with AKT pathway blockade. Pharmacokinetic studies established that potentially active concentrations of CCT128930 could be achieved in human tumor xenografts. Furthermore, CCT128930 also blocked the phosphorylation of several downstream AKT biomarkers in U87MG tumor xenografts, indicating AKT inhibition in vivo. Antitumor activity was observed with CCT128930 in U87MG and HER2-positive, PIK3CA-mutant BT474 human breast cancer xenografts, consistent with its pharmacokinetic and pharmacodynamic properties. A quantitative immunofluorescence assay to measure the phosphorylation and total protein expression of the AKT substrate PRAS40 in hair follicles is presented. Significant decreases in pThr246 PRAS40 occurred in CCT128930-treated mouse whisker follicles in vivo and human hair follicles treated ex vivo, with minimal changes in total PRAS40. In conclusion, CCT128930 is a novel, selective, and potent AKT inhibitor that blocks AKT activity in vitro and in vivo and induces marked antitumor responses. We have also developed a novel biomarker assay for the inhibition of AKT in human hair follicles, which is currently being used in clinical trials. Mol Cancer Ther; 10(2); 360–71. ©2010 AACR.

The serine/threonine kinase AKT plays a pivotal role in signal transduction events involved in malignant transformation and chemoresistance and is an attractive target for the development of cancer therapeutics. Fragment-based lead discovery, combined with structure-based drug design, has recently identified AT7867 as a novel and potent inhibitor of both AKT and the downstream kinase p70 S6 kinase (p70S6K) and also of protein kinase A. This ATP-competitive small molecule potently inhibits both AKT and p70S6K activity at the cellular level, as measured by inhibition of GSK3β and S6 ribosomal protein phosphorylation, and also causes growth inhibition in a range of human cancer cell lines as a single agent. Induction of apoptosis was detected by multiple methods in tumor cells following AT7867 treatment. Administration of AT7867 (90 mg/kg p.o. or 20 mg/kg i.p.) to athymic mice implanted with the PTEN-deficient U87MG human glioblastoma xenograft model caused inhibition of phosphorylation of downstream substrates of both AKT and p70S6K and induction of apoptosis, confirming the observations made in vitro. These doses of AT7867 also resulted in inhibition of human tumor growth in PTEN-deficient xenograft models. These data suggest that the novel strategy of AKT and p70S6K blockade may have therapeutic value and supports further evaluation of AT7867 as a single-agent anticancer strategy. Mol Cancer Ther; 9(5); 1100–10. ©2010 AACR.

M30 and M65 are ELISAs that detect different circulating forms of cytokeratin 18. Using the aurora kinase inhibitor AZD1152 and the SW620 human colon cancer xenograft, experiments were conducted to qualify preclinically both assays as serologic biomarkers of cell death. Using two different apoptotic markers, the kinetics of cell death induced by AZD1152 was first characterized in vitro in three different cell lines and shown to peak 5 to 7 days after drug addition. Treatment of non-tumor-bearing rats with AZD1152 (25 mg/kg) produced no alterations in circulating baseline values of M30 and M65 antigens. In treated, tumor-bearing animals, M30 detected a 2- to 3-fold (P < 0.05) increase in plasma antigen levels by day 5 compared with controls. This correlated to a 3-fold increase in the number of apoptotic cells detected on day 5 in SW620 xenografts using immunohistochemistry. By contrast, M65 did not detect a drug-induced increase in circulating antigen levels at day 5. However, M65 plasma levels correlated to changes in tumor growth in control animals (r2 = 0.93; P < 0.01) and also followed the magnitude of the temporal effect of AZD1152 on tumor growth. An intermediate but active dose of AZD1152 (12.5 mg/kg) produced a less significant increase in M30 plasma levels at day 5. It was also confirmed that the plasma profiles of M30 and M65 mirrored closely those measured in whole tumor lysates. We conclude that M30 is a pharmacodynamic biomarker of AZD1152-induced apoptosis in the SW620 xenograft model, whereas M65 is a biomarker of therapeutic response. [Mol Cancer Ther 2008;7(3):455–63]

A new class of 1-acetanilide-4-aminopyrazole-substituted quinazoline Aurora kinase inhibitors has been discovered possessing highly potent cellular activity. Continuous infusion into athymic mice bearing SW620 tumors of the soluble phosphate derivative 2 led to dose-proportional exposure of the des-phosphate compound 8 with a high-unbound fraction. The combination of potent cell activity and high free-drug exposure led to pharmacodynamic changes in the tumor at low doses, indicative of Aurora B-kinase inhibition and a reduction in tumor volume.

Purpose: In the current study, we examined the in vivo effects of AZD1152, a novel and specific inhibitor of Aurora kinase activity (with selectivity for Aurora B). Experimental Design: The pharmacodynamic effects and efficacy of AZD1152 were determined in a panel of human tumor xenograft models. AZD1152 was dosed via several parenteral (s.c. osmotic mini-pump, i.p., and i.v.) routes. Results: AZD1152 potently inhibited the growth of human colon, lung, and hematologic tumor xenografts (mean tumor growth inhibition range, 55% to ≥100%; P < 0.05) in immunodeficient mice. Detailed pharmacodynamic analysis in colorectal SW620 tumor-bearing athymic rats treated i.v. with AZD1152 revealed a temporal sequence of phenotypic events in tumors: transient suppression of histone H3 phosphorylation followed by accumulation of 4N DNA in cells (2.4-fold higher compared with controls) and then an increased proportion of polyploid cells (>4N DNA, 2.3-fold higher compared with controls). Histologic analysis showed aberrant cell division that was concurrent with an increase in apoptosis in AZD1152-treated tumors. Bone marrow analyses revealed transient myelosuppression with the drug that was fully reversible following cessation of AZD1152 treatment. Conclusions: These data suggest that selective targeting of Aurora B kinase may be a promising therapeutic approach for the treatment of a range of malignancies. In addition to the suppression of histone H3 phosphorylation, determination of tumor cell polyploidy and apoptosis may be useful biomarkers for this class of therapeutic agent. AZD1152 is currently in phase I trials.

The Aurora kinases have been the subject of considerable interest as targets for the development of new anticancer agents. While evidence suggests inhibition of Aurora B kinase gives rise to the more pronounced antiproliferative phenotype, the most clinically advanced agents reported to date typically inhibit both Aurora A and B. We have discovered a series of pyrazoloquinazolines, some of which show greater than 1000-fold selectivity for Aurora B over Aurora A kinase activity, in recombinant enzyme assays. These compounds have been designed for parenteral administration and achieve high levels of solubility by virtue of their ability to be delivered as readily activated phosphate derivatives. The prodrugs are comprehensively converted to the des-phosphate form in vivo, and the active species have advantageous pharmacokinetic properties and safety pharmacology profiles. The compounds display striking in vivo activity, and compound 5 (AZD1152) has been selected for clinical evaluation and is currently in phase 1 clinical trials.

The synthesis of a novel series of quinazolines substituted at C4 by five-membered ring aminoheterocycles is reported. Their in vitro structure-activity relationships versus Aurora A and B serine-threonine kinases is discussed. Our results demonstrate that quinazolines with a substituted aminothiazole at C4 possess potent Aurora A and B inhibitory activity and excellent selectivity against a panel of various serine-threonine and tyrosine kinases, as exemplified by compound 46. We found also that the position and nature of the substituent on the thiazole play key roles in cellular potency. Compounds with an acetanilide substituent at C5' have the greatest cellular activity. The importance of the C5' position for substitution has been rationalized by ab initio molecular orbital calculations. Results show that the planar conformation with the sulfur of the thiazole next to the quinazoline N-3 is strongly favored over the other possible planar conformation. Compound 46 is a potent suppressor of the expression of phospho-histone H3 in tumor cells in vitro as well as in vivo, where 46, administered as its phosphate prodrug 54, suppresses the expression of phospho-histone H3 in subcutaneously implanted tumors in nude mice.

Tissue microarray (TMA) technology is currently being utilized as a complimentary histological tool for both normal target distribution and evaluation of pharmacodynamic biomarkers in support of the drug discovery process. The Automated Cellular Imaging System (ACIS-Clarient Chromavision) provides a rapid, precise approach to the quantitative analysis of immunohistochemically localised protein within TMAs. This system utilizes colour space analysis to determine the percentage of protein localization, in relation to a selected counterstained tissue component area, and relative optical intensity as an indication of protein density in TMAs. We describe the use of the ACIS under two situations (1) identification of novel target molecule distribution in normal animal TMAs and (2) analysis of a panel of immunohistochemical biomarkers to determine mode of action of novel anti-cancer drugs in xenograft TMAs. In the first case, the approach taken was to utilise a two-tiered analysis, identifying that protein expression was present in any particular tissue core and then reviewing those cores for the specific cellular distribution of protein. In the second example, immunohistochemistry on TMA samples was used to determine the pharmacological effects of small molecule inhibitors on molecular targets and linked pathways, including apoptosis and endoreduplication. TMAs were also stained by the histochemical Blue Feulgen method for ploidy evaluation on the ACIS. These analyses have indicated the value of using a combination of Chromavision ACIS and histological analysis of TMAs for both novel target distributions in drug discovery and in predicting the efficacy of cyclin and mitosis inhibitors in preclinical models.

3022 Background: The phosphatidylinositol 3-kinase (PI3K) pathway is a promising target in cancer. CH5132799 is a novel PI3K inhibitor, selectively inhibiting class I PI3Ks (α, β, δ and γ) with no inhibition of class II and III or mTOR, and with potent antitumor activity in preclinical studies (Tanaka et al, Clin Cancer Res; 17; 3272-81, 2011). First-in-human study objectives were determination of maximum tolerated dose (MTD), safety/tolerability, PK/PD and clinical activity (RECIST). Methods: A 3+3 dose escalation design was used. The initial dosing schedule of CH5132799(schedule A) was once a day (QD). Due to a relatively short half-life, a twice a day (BID) schedule (schedule B) was introduced. PK profiles were studied over 72 hours. PD analyses included quantification of various phosphoproteins in platelet rich plasma (PRP). Tumor assessments were performed at baseline and cycle 3 day 1 (C3D1) and FDG-PET scans at baseline, C1D8 and C3D1. Results: 29 patients (pts) with a variety of solid tumors have been treated (A 23 pts, B 6 pts, the most common tumors were breast, oesophageal, colorectal and ovarian). The starting doses were 2 mg (A) and 48 mg (B). The current doses being explored are 96 mg (A) and 72 mg (B). The most frequently reported drug-related AEs were Grade 1/2 diarrhea, nausea, fatigue, anorexia and anemia. 1 DLT (Grade 3 elevated LFT) was observed in a hepatocellular carcinoma pt at 48 mg BID. MTD has not yet been determined. The preliminary mean ±SD Cmax and AUC at 96 mg QD were 202±129 ng/ml and 1407±935 ng·hr/ml respectively, which is consistent with an efficacious exposure based on preclinical models. Some patients achieved the expected exposure at over 32 mg. From single dose of 48mg there was a reduction of phosphorylation of AKT in PRP after treatment, consistent with pathway modulation. A patient with clear cell ovarian cancer and a PIK3CA mutation treated at 48 mg BID showed >50% decrease in SUV on a PET scan at C1D8 and a 75% decrease in CA-125 at C2D1. 5 pts exhibited SD (>8 weeks). Conclusions: CH5132799 is well tolerated either QD ≤96 mg or BID ≤48 mg. Dose-escalation continues and updated safety/efficacy/PK/PD data will be presented.

The AGC kinase AKT is a key component of the phosphatidylinositol 3-kinase (PI3K) pathway, which is frequently deregulated in cancer, making AKT a target of major therapeutic interest. However, PI3K signaling through both AKT-dependent and AKT-independent mechanisms involving other AGC kinases, such as p70S6K, PKA, SGK and ROCK, is important in a range of cancers. Hence, the pharmacological inhibition of these multiple AGC kinases may increase response rates and minimize clinical resistance compared with targeting AKT alone. The clinical drug candidate AT13148 is a multi-AGC kinase, ATP-competitive inhibitor, identified utilizing high-throughput X-ray crystallography and fragment-based lead discovery techniques. Screening of this oral small molecule against a panel of kinases at 10μM revealed >80% inhibition of the structurally related AGC kinases AKT, PKA, ROCK2, p70S6K, MSK, RSK1/2, and SGK. We demonstrate that AT13148 has antiproliferative activity in a range of in vitro models harboring relevant genetic abnormalities, including PTEN, KRAS, PIK3CA and HER2 aberrations. AT13148 caused substantial blockade of AKT, p70S6K, PKA, ROCK and SGK substrate phosphorylation and induction of apoptosis in both a concentration and time-dependent manner in cancer cells with clinically relevant genetic defects both in vitro and in vivo. Antitumor efficacy in HER2-positive, PIK3CA-mutant BT474 breast, PTEN-deficient PC3 human prostate cancer and PTEN-deficient MES-SA uterine tumor xenografts was demonstrated. We show for the first time that induction of AKT phosphorylation at serine 473 by AT13148, as reported for other ATP competitive inhibitors of AKT, is not a therapeutically relevant reactivation step for this compound. We used gene expression microarray studies to characterize the underlying molecular mechanisms of action of AT13148 and the selective AKT inhibitor CCT128930, and observed the induction of upstream regulators including insulin receptor substrate-2 and PIK3IP1 due to compensatory feedback loops, consistent with blockade of AKT signaling. These studies also showed that AT13148 and CCT128930 have distinct molecular effects in cancer cells: AT13148 had a predominant effect on apoptosis genes and caused a greater apoptotic phenotype, while CCT128930 modulated genes in the network regulating cell cycle. This finding emphasizes the functional differences of AT13148 as a multi-AGC kinase inhibitor in contrast to a more AKT-selective inhibitor. In view of the potential mechanistic advantages detailed above, and the potent antitumor activity observed at well tolerated doses against established human tumor xenografts with clinically relevant genetic drivers, the clinical utility of such an AGC kinase inhibitor strategy will now be assessed in a first-in-human Phase I trial of AT13148. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 928. doi:1538-7445.AM2012-928

Background Weekly administration of paclitaxel is increasingly used to treat patients with platinum-resistant ovarian cancer. We have previously reported that activation of the phosphatidylinositide-3-kinase pathway as measured by p-p70S6K is associated with resistance to chemotherapy in studies using ovarian cancer cells isolated from ascites (Carden et al, 101st AACR Annual Meeting, 2010; Abstract no. 788). We thus set out to explore the combination of paclitaxel and an inhibitor of the mTORC1/2 complex, AZD2014, in ovarian cancer cell line models. Purpose We aimed to study the effects of combining paclitaxel and the mTORC1/2 inhibitor AZD2014 on growth inhibition in a panel of human ovarian cancer cell lines. We also studied the effects of drug administration schedule on growth inhibition. Methods A panel of 5 human ovarian cell lines was studied: A2780, CH1, SKOV3, IGROV and OVCAR-3. The effects of paclitaxel and AZD2014 administered concomitantly on cell growth were studied using 96hr sulforhodamine B assays. Combination indices (CI) were calculated using median effect analysis and a one-sided t-test was performed to calculate significant differences from a hypothetical value of 1 (indicating additivity). All experiments were carried out in triplicate. Results The combination was additive when drugs were administered concomitantly. In addition, in A2780 and SKOV3 cell lines exposed to paclitaxel followed by AZD2014 the combination indices were 1.112 and 1.099 respectively. Conclusion AZD2014, a novel mTORC1/2 inhibitor, and paclitaxel have additive growth inhibitory effects in a panel of ovarian cancer cell lines when administered concomitantly. Further experiments to understand the effects of this combination on apoptosis and signal transduction are ongoing. The combination of AZD2014 and paclitaxel has potential applications in the treatment of ovarian cancer. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 931. doi:1538-7445.AM2012-931

3037^ Background: AKT is a key regulator of cellular proliferation, apoptosis and growth. A range of cancers have genetic aberrations that involve the PI3K/AKT pathway, leading to abnormal AKT hype...

3001^ Background: MK-2206 is a novel allosteric inhibitor of all 3 isoforms of AKT, which are targets implicated in malignant progression. Methods: The investigational agent MK-2206 was given orally QOD to patients (pt) with advanced solid tumors. PD studies of AKT and downstream protein phosphorylation (p) were carried out in tumor biopsies and platelet-rich plasma with MesoScale Discovery (MSD) ELISA, and hair follicles with immunofluorescence. Tumor biopsies were sequenced with Sequenom Oncocarta panel for putative predictive biomarkers and stained with IHC for PTEN expression. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), MR spectroscopy (MRS) and diffusion weighted imaging (DWI) were conducted. Results: 71 pt (37 M; median age 59y; ECOG PS 0/1: 22/49) received MK-2206 at 30, 60, 75, 90 mg QOD. G3 rash (n=6) was dose limiting at 75-90 mg QOD, establishing MTD at 60mg QOD. Four MTD expansion cohorts were then undertaken: paired tumor biopsies (n=14), functional imaging (n=13), ovarian...

Background: Akt signaling plays a key role in cell proliferation, growth and survival, and is commonly deregulated in human cancers. MK inhibits Akt1/2/3, with nanomolar IC50 and has broad preclinical antitumor activity. Methods: MK was administered either every second day (QOD) or weekly (QW), due to a predicted long elimination half-life, in a Phase I dose escalation trial. Detailed pharmacokinetic-pharmacodynamic (PK-PD) studies were pursued. At MTD, mandatory pre- and post-MK tumor biopsies (n=12) were carried out to confirm target inhibition; expanded cohorts of ovarian (n=12) and prostate cancers (n=12) were also assessed. Archival tumor and circulating nucleic acid were analyzed for PTEN loss and PIK3CA mutations respectively. PD studies included Meso Scale Discovery (MSD) ELISA and immunohistochemical (IHC) analyses of Akt phosphorylation and of its downstream targets in tumor; MSD in platelet-rich plasma (PRP); and immunofluorescence in hair follicles. Results: 58 pts (25 F/33 M; median age 60 years; ECOG PS 0/1: 16/42) received MK in either QOD or QW schedules. 45 pts received MK at 30, 60, 75 or 90 mg QOD. The QOD MTD was 60 mg, with dose limiting toxicities (DLT) of CTCAE G3/4 skin rash and G3 mucositis. QW MTD is currently being established; to date, 13 pts have received MK at 90, 135, 200 and 300 mg QW. Common drug-related toxicities include hyperglycemia (42.9%), skin rash (39.6%), nausea and fatigue (27.1%), and diarrhea (20.8%). PK (AUC0-48hr and Cmax) was dose-proportional up to 60 mg QOD and at 135 mg QW. Median Tmax was 6-8 hours and mean t1/2 ranged from 55 to 78 hours. Plasma concentrations of MK achieved preclinically established PK targets for significant phosphorylated Ser473 AKT (pAKT) inhibition. Robust pAKT inhibition of ∼70% by MSD was observed in paired tumor biopsies (6 of 9 pts) in the 60 mg QOD biopsy cohort, confirming target modulation at this MTD dose. At 60 mg QOD, these tumor PD effects correlated with statistically significant decreases in pAKT in PRP (p Conclusions: MK is generally well tolerated at the MTD of 60 mg QOD. Profound AKT signaling blockade was reported, including antitumor activity in a pt with PTEN loss. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 27.

Deregulated AKT signalling is implicated in cancer. The preclinical characterization of AKT inhibitors and development of PD biomarkers are vital prior to clinical trials. Invasive techniques for clinical PD analyses pose ethical and logistical issues, hence hair follicles may represent a non-invasive option. The pyrazole AT7867 and pyrrolopyrimidine CCT128930 are novel ATP-competitive AKT inhibitors from different chemical series developed at The Institute of Cancer Research in collaboration with Astex Therapeutics (Cambridge, UK). AT7867 and CCT128930 have IC50 values against AKT2 of 17nM and 6nM respectively. Growth inhibitory IC50 (GI50) values were 2.4μM and 6.3μM in PTEN-null U87MG glioblastoma cells as measured by SRB assay. Cellular studies of both compounds in U87MG cells were carried out by Meso Scale Discovery (MSD) ELISA, western blot (WB) and immunofluorescence. These showed an initial induction of phosphorylated (p) Ser473 AKT as expected with ATP-competitive AKT inhibitors, and inhibition of downstream AKT targets, including pSer9 GSK-3β, pThr246 PRAS40, pSer127 YAP and pSer235/236 S6RP, indicating AKT pathway blockade. Interestingly, CCT128930 inhibited phosphorylation of AKT targets GSK-3β, S6RP and PRAS40 at lower concentrations (0.5-1µM), compared to AT7867 (5-10µM) in U87MG cells. Phosphorylation was also inhibited at earlier time points with equipotent doses (3XGI50) of CCT128930 versus AT7867. CCT128930 also caused a predominant G0/G1 phase arrest, while AT7867 resulted in a predominant G2 arrest in U87MG cells at equipotent doses (3XGI50), using BrdU and PI staining and flow cytometry. We report for the first time in vivo efficacy with intraperitoneally (ip) or orally administered AT7867 in PTEN-null MES-SA uterine sarcoma and U87MG mouse xenograft models; and ip administered CCT128930 in HER2-overexpressing BT474 breast cancer and U87MG xenografts, which correlated with in vivo pharmacokinetics (PK) and PD biomarker modulation of pSer9 GSK-3β and pSer235/236 S6RP using WB and MSD. Hair follicles were developed as a robust surrogate PD biomarker, with pThr246 PRAS40 as a PD readout. This assay was validated with healthy volunteer hair follicles, which were treated ex vivo with CCT128930. A significant decrease in pThr246 PRAS40 (p In conclusion, by employing an integrated PK and PD biomarker-driven drug discovery strategy, we have developed 2 novel and potent AKT inhibitors with antitumor activity, and have validated a robust surrogate biomarker assay for AKT inhibition for use in clinical trials. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4481.

Future cancer treatment regimes may involve novel drug combinations aimed at targeting different pathways involved in tumour proliferation and survival. Understanding the mechanisms involved in such combinations and identifying the optimum schedule/sequence will be key to guiding clinical development. The Aurora kinases play a critical role in mitosis and have been suggested as promising targets for therapy due to their frequent over expression in a variety of tumours. AZD1152 is a selective Aurora B kinase inhibitor, with a novel anti-tumour mechanism of action, inducing endoreduplication, apoptosis and inhibition of cytokinesis. The MAPK signaling pathway is implicated in uncontrolled cell proliferation and cell survival in many cancers. AZD6244 (ARRY-142886), a selective, ATP non-competitive inhibitor of MEK1/2, has demonstrated G1 arrest and anti-tumour activity in a range of preclinical models. In the present study, we dosed AZD1152 and AZD6244 in combination to nude mice bearing human NSCLC tumour (Calu-6) xenografts. Pharmacodynamic analysis of Calu-6 xenografts treated with either AZD1152 or AZD6244 as monotherapies (MonTx) indicated downstream biomarker effects in accordance with their targets (for e.g. suppression of phosphorylation of histone H3 and ERK, respectively). When the same doses of AZD1152 (150mg/Kg/day s.c. for 2 days via osmotic minipumps) or AZD6244 (25mg/kg/BID p.o.) were dosed in a chronic disease setting, both drugs significantly suppressed Calu-6 tumour growth (versus respective vehicle groups, p → AZD6244 proved superior to both MonTx arms in terms of apoptosis induction and tumour growth inhibition. These data indicate a promising therapeutic strategy for combining AZD1152 and AZD6244, and suggest that the sequence of drug administration may be critical when combining these inhibitors. Both AZD1152 and AZD6244 are currently in clinical trials. Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4434.

Background: JNJ-26481585 is a potent histone deacetylase (HDAC) inhibitor. It is undergoing evaluation in phase I trials in solid tumours. The drug has shown plasma concentrations consistent with activity in preclinical models and target inhibition in surrogate and tumour tissue. Purpose: To determine the mechanism of action of JNJ-26481585 and to study factors determining sensitivity to the drug in-vitro in the setting of melanoma cell lines. Experimental Procedures: Array comparative genomic hybridization (array CGH) was carried out to study gene copy number. The growth inhibitory (GI50) concentrations of JNJ-26481585 and 17-allylamino, 17-demethoxygeldanamyin (17-AAG) were determined by sulforhodamine (SRB) assays. A panel of melanoma cell lines was exposed to GI50 and 5 X GI50 for 24hrs and gene expression profiling was performed using gene expression microarrays. Changes in protein expression were studied by western blot analysis. Results: Cells exposed to GI50 and 5X GI50 of 17-AAG for 24hrs showed a molecular signature of HSP90 inhibition including C-RAF depletion and HSP70 induction while this was not the case in equitoxic concentrations of JNJ-26481585. In addition, JNJ-26481585 did not reproducibly induce acetylation of tubulin which is a surrogate for cytoplasmic acetylation of proteins such as HSP90. JNJ-26481585 however induced robust acetylation of histone H3 suggestive of its mechanism of action predominantly as a class I HDAC inhibitor. The micropthalmia associated transcription factor (MITF) locus was amplified in the SKMEL-28 cells. The GI50 concentrations of JNJ-26481585 in the cell lines SKMEL-28, WM266.4, A2058, SKMEL-2 and SKMEL-5 were 5.4 (SD 0.86) nM, 20 (SD 0.58) nM, 28.1 (SD 0.7) nM, 30.4 (SD 3.6) nM, 33.4 (SD 3.6) nM respectively. The cell line panel was exposed to GI50 and 5 X GI50 of JNJ-26481585 for 24hrs. Protein levels of MITF was depleted in addition to MITF m-RNA levels being significantly reduced; p=0.002 (Welch T test with Benjamini and Hochberg correction for multiple testing; FDR 5%) at the time points studied, suggesting down regulation of MITF gene expression as a possible mechanism of action of JNJ-26481585. All the cell lines studied underwent apoptosis as evidenced by demonstration of cleaved PARP on western blotting. Conclusions: In this model, the mechanism of action of JNJ-26481585 is not predominantly due to HSP90 inhibition caused by acetylation of HSP90 in melanoma cells. Melanoma cell lines which have an amplification of MITF are sensitive to the HDAC inhibitor JNJ-26481585. Further exploration of MITF protein to evaluate pharmacodynamic response of JNJ-26481585 is warranted. Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 5440.

Background: Akt is a key mediator of cell proliferation, growth and survival, and is deregulated in a range of human cancers. MK-2206 is a highly selective, potent allosteric non-ATP competitive inhibitor of Akt1, 2 and 3, with nanomolar IC50 and broad preclinical antitumor activity. Methods: MK-2206 was administered on alternate days (QOD) and weekly (QW) in 28-day cycles, with assessment of safety, pharmacokinetics (PK), pharmacodynamics (PD) and preliminary antitumor efficacy. PD studies included mesoscale discovery ELISA (MSD) and immunohistochemical (IHC) analyses of Akt and downstream substrates in tumor biopsies, as well as in platelet-rich plasma (PRP) by MSD and plucked hair follicles by immunofluorescence. Once MTD was established, paired pre- and post-treatment tumor biopsies were mandated in a separate cohort of 12 pts to confirm target inhibition. The MTD is currently being explored in ovarian cancer (n=12) and CRPC (n=12) cohorts. Circulating nucleic acid and tumor tissue were analyzed for PIK3CA mutations and PTEN status respectively and correlated with antitumor efficacy. Results: 48 pts (23 F/25 M; median age 57 years; ECOG performance status 0/1: 24/24) received MK-2206 in either QOD or QW schedules. Following evaluation of 19 pts at doses 30, 60, 75 and 90 mg, the QOD MTD was established at 60 mg, with dose limiting toxicities (DLT) of CTCAE G3/4 skin rash and G3 mucositis. QW dose escalation is ongoing (doses 90, 135 and 200 mg) with no DLT observed. Common drug-related toxicities include hyperglycemia (42.9%), skin rash (39.6%), nausea and fatigue (27.1%), and diarrhea (20.8%). PK (AUC0–48hr and Cmax) was dose proportional up to 60 mg QOD and at 90 mg QW. Median Tmax was 6–8 hrs and mean t1/2 ranged from 55 to 78 hr. The observed MK-2206 plasma concentrations achieved preclinically established PK targets for significant phosphorylated AKT (pAKT) inhibition in blood. Robust pAKT inhibition of approximately 90% was observed in paired tumor biopsies (5 of 7 pts) at 60 mg QOD, confirming target modulation at this dose level. This was supported by substantial decreases in pAKT and downstream biomarker signals e.g. pGSK3 in PRP in pts tested in the 60 mg QOD and 90 mg and higher QW cohorts, as well as asymptomatic reversible G1-3 hyperglycemia and G1 insulin c-peptide elevation. Observed antitumor activity included: tumor regression, CA125 declines, PSA stabilization, central tumor necrosis, liver function normalization, and decreased ascites. Conclusions: MK-2206 is generally well tolerated at the MTD of 60 mg QOD with dose proportional PK, substantial and sustained pAKT inhibition in tumor with supporting evidence in surrogate tissue confirming target modulation, and preliminary clinical activity. Dose escalation continues with the QW schedule. Citation Information: Mol Cancer Ther 2009;8(12 Suppl):B135.