Title of Invention	PHARMACEUTICAL COMPOSITIONS WITH RECEPTOR TYROSINE KINASE INHIBITORS AND ANGIOGENESIS INHIBITORS
Abstract	The invention relates to a combination therapy for the treatment of tumors and tumor metastases comprising administration of receptor tyrosine kinase antagonists/inhibitors, especially ErbB receptor antagonists, more preferably EGF receptor (Her 1)antagonists and anti-angiogenic agents, preferably integrin antagonists, optionally together with agents or therapy forms that have additive or synergistic efficacy when administered together with said combination of antagonists/inhibitors, such as chemotherapeutic agents and or radiation therapy. The therapy can result in a synergistic potential increase of the inhibition effect of each individual therapeutic on tumor cell proliferation, yielding more affective treatment than found by administering an individual component alone.

Title of Invention

PHARMACEUTICAL COMPOSITIONS WITH RECEPTOR TYROSINE KINASE INHIBITORS AND ANGIOGENESIS INHIBITORS

Abstract

The invention relates to a combination therapy for the treatment of tumors and tumor metastases comprising administration of receptor tyrosine kinase antagonists/inhibitors, especially ErbB receptor antagonists, more preferably EGF receptor (Her 1)antagonists and anti-angiogenic agents, preferably integrin antagonists, optionally together with agents or therapy forms that have additive or synergistic efficacy when administered together with said combination of antagonists/inhibitors, such as chemotherapeutic agents and or radiation therapy. The therapy can result in a synergistic potential increase of the inhibition effect of each individual therapeutic on tumor cell proliferation, yielding more affective treatment than found by administering an individual component alone.

Full Text	COMOINATION THERAPY USING RECEPTOR TYROSINE KINASE INHIBITORS AND ANGIOGENESIS INHIBITORS TECHNICAL FIELD OF THE INVENTION: The invention relates to a combination therapy for the treatment of tumors and tumor metastases comprising administration of receptor tyrosine kinase antagonists/ inhibitors, especially ErbB receptor antagonists, more preferably EGF receptor (Her 1) antagonists and anti-angiogenic agents, preferably integrin antagonists, optionally together with agents or therapy forms that have additive or synergistic efficacy when administered together with said combination of antagonists/inhibitors, such as chemotherapeutic agents and or radiation therapy. The therapy can result in a synergistic potential increase of the inhibition effect of each individual therapeutic on tumor cell proliferation, yielding more effective treatment than found by administering an individual component alone. BACKGROUND OF THE INVENTION: The epidermal growth factor receptor (EGF receptor or EGFR), also known as c- erbB1/Her 1, and the product of the neu oncogene (also known as c-erbB2/Her 2) are the members of the EFG receptor super family, which belongs to the large family of receptor tyrosine kinases. They interact at the cell surface with specific growth factors or natural ligands, such as EGF or TGF alpha, thus, activating the receptor tyrosine kinase. A cascade of downstream signaling proteins are activated in general leading to altered gene expression and increased growth rates. C-erbB2 (Har 2) is a transmembrane tyrosine kinase having a molecular weight of, about 185(000, with considerable homology to the EGF receptor (Her 1), although a specific ligand for Her 2 has not yet been clearly identified so far. The .EGF receptor is a transmembrane glycoprotein which has a molecular weight of 170.000, And is found on many epithelial cell types. It is activated by at least three ligands, EGF, TGF-α (transforming growth factor alpha) and amphiregulin. Both epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-a) have been demonstrated to bind to EGF receptor and to lead to cellular proliferation and tumor growth. These growth factors do not bind to Her 2 (Ulrich and Schlesinger, 1990, Cell 61, 203). In contrast to several families of growth factors, which induce receptor dimerization by virtue of their dimeric nature (e.g. PDGF) monomeric growth factors, such as EGF, contain two binding sites for their receptors and, therefore, can cross-link two neighboring EGF receptors (Lemmon et al., 1997, EMBO J. 16,281). Receptor dimerization is essential for stimulating of the intrinsic catalytic activity and for the autophosphorylation of growth factor receptors. It should be remarked that receptor protein tyrosine kinases (PTKs) are able to undergo both homo- and heterodimerization. Clinical studies indicate that both EGF receptor and c-erbB2 are overexpressed in certain types of tumors, especially, breast, ovary, bladder, colon, kidney, head and neck cancers and squamous carcinomas of the lung. (Mendelsohn, 1989, Cancer Cells 7,359; Mendelsohn, 1990, Cancer Biology 1, 339). Therefore, these observations have stimulated preclinical investigations targeting on inhibiting the function of human EGF receptors or c-erbB2 as novel therapeutic approaches to treat cancer (see e.g. Baselga et al., 1996, J. Clin. Oncol. 14, 737; Fan and Mendelsohn, 1998, Curr. Opin. Oncol. 10, 67). It has been reported that, for example, anti-EGF receptor antibodies as well as anti-Her 2 antibodies show fruitful results in human cancer therapy. Thus, humanized monoclonal antibody 4D5 (hMAb 4D5, HERCEPTIN®) is already a commercialized product. It has been demonstrated that anti-EGF receptor antibodies while blocking EGF and TGF-a binding to the receptor appear to inhibit tumor cell proliferation. In view of these findings, a number of murine and rat monoclonal antibodies against EGF receptor have been developed and tested for their ability inhibit the growth of tumor cells in vitro and in vivo (Modjtahedi and Dean, 1994, J. Oncology 4, 277). Humanized monoclonal antibody 425 (hMAb 425) (US 5,558,864; EP 0531 472) and chimeric monoclonal antibody 225 (cMAb 225) (Naramura et al., 1993, Cancer Immunol. Immunother. 37, 343-349.WO 96/40210), both directed to the EGF receptor, have shown their efficacy in clinical trials. The C225 antibody was demonstrated to inhibit EGF-mediated tumor cell growth in vitro and inhibit human tumor formation in vivo in nude mice. The antibody, moreover, appeared to act, above all, in synergy with certain chemotherapeutic agents (i.e., doxorubicin, adriamycin, taxol, and cisplatin) to eradicate human tumors in vivo in xenograft mouse models. Ye et al. (1999, Oncogene 18, 731) have reported that human ovarian cancer cells can be treated successfully with a combination of both cMAb 225 and hMAb 4D5. Angiogenesis, also referred to as neovascularization, is a process of tissue vascularization that involves the growth of new blood vessels into a tissue. The process is mediated by the infiltration of endothelial cells and smooth muscle ceils. The process is believed to proceed in any one of three ways: (1) the vessels can sprout from pre-existing vessels; (2) de novo development of vessels can arise from precursor cells (vasculogenesis); or (3) existing small vessels can enlarge in diameter (Blood et al., 1990, Bioch. Biophys. Acta 1032, 89. Vascular endothelial cells are known to contain at least five RGD-dependent integrins, including the vitronectin receptor (αvβ3 or αvβ3), the collagen Types I and IV receptor, the laminin receptor, the fibronectin/laminin/collagen receptor and the fibronectin receptor (Davis et al., 1993, J. Cell. Biochem. 51, 206). The smooth muscle cell is known to contain at least six RGD-dependent integrins, including αvβ3 αvβ5. Inhibition of cell adhesion in vitro using monoclonal antibodies immunospecific for various integrin a or B subunits have implicated the vitronectin receptor αvβ3 in cell adhesion of a variety of cell types including microvascular endothelial cells (Davis et al., 1993, J. Cell. Biol. 51, 206). Integrins are a class of cellular receptors known to bind extracellular matrix proteins, and mediate cell-extracellular matrix and cell-cell interactions, referred generally to as cell adhesion events. The integrin receptors constitute a family of proteins with shared structural characteristics of non-covalent heterodimeric glycoprotein complexes formed of a and 3 subunits. The vitronectin receptor, named for its original characteristic of preferential binding to vitronectin, is now known to refer to three different integrins, designated αvβ1, αvβ3 and avB5. αvβ1 binds fibronectin and vitronectin. αvβ3 binds a large variety of ligands, including fibrin, fibrinogen, laminin, thrombospondin, vitronectin and von Willebrand's factor. αvβ5 binds vitronectin. It is clear that there are different integrins with different biological functions as well as different integrins and subunits having shared biological specificity and function. One important recognition site in a ligand for many integrins is the arginine-glycine- aspartic acid (RGD) tripeptide sequence. RGD is found in all of the ligands identified above for the vitronectin receptor integrins. This RGD recognition site can be mimicked by linear and cyclic (poly)peptides that contain the RGD sequence. Such RGD peptides are known to be inhibitors or antagonists, respectively, of integrin function. It is important to note, however, that depending upon the sequence and structure of the RGD peptide, the specificity of the inhibition can be altered to target specific integrins. Various RGD polypeptides of varying integrin specificity have been described, for example, by Cheresh, et al., 1989, Cell 58, 945, Aumailley et al., 1991, FEBS Letts. 291,50, and in numerous patent applications and patens (e.g. US patents 4,517,686, 4,578,079, 4,589,881,4,614,517, 4,661,111, 4,792,525; EP 0770 622). The generation of new blood vessels, or angiogenesis, plays a key role in the growth of malignant disease and has generated much interest in developing agents that inhibit angiogenesis (see, for example, Holmgren et al., 1995, Nature Medicine 1, 149; Folkman, 1995, Nature Medicine 1, 27; O'Reilly et. al., 1994, Cell 79, 315). The use of αvβ3 integrin antagonists to inhibit angiogenesis is known in methods to inhibit solid tumor growth by reduction of the blood supply to the solid tumor (see, for example, US 5,753,230 and US 5,766,591, which describe the use of αvβ3 antagonists such as synthetic polypeptides, monoclonal antibodies and mimetics of αvβ3 that bind to the αvβ3 receptor and inhibit angiogenesis). Methods and compositions for inhibiting αvβ5 mediated angiogenesis of tissues using antagonists of the vitronectin receptor αvβ3 are disclosed in WO 97/45447. Angiogenesis is characterized by invasion, migration and proliferation of endothelial cells, processes that depend on cell interactions with extracellular matrix components. In this context, the integrin cell-matrix receptors mediate cell spreading and migration. The endothelial adhesion receptors of integrin αvβ3 were shown to be key players by providing a vasculature-specific target for anti-angiogenic treatment strategies (Brooks et al., 1994, Science 264, 569; Friedlander et. al., 1995, Science 270). The requirement for vascular integrin αvβ3 in angiogenesis was demonstrated by several in vivo models where the generation of new blood vessels by transplanted human tumors was entirely inhibited either by systemic administration of peptide antagonists of integrin αvβ3 and αvβ3, as indicated above, or, alternatively, by anti- αvβ3 antibody LM609 (Brooks et al., 1994, Cell 79, 1157; ATCC HB 9537). This antibody blocks the αvβ3 integrin receptor the activation of which by its natural ligands promotes apoptosis of the proliferative angiogenic vascular cells and thereby disrupts the maturation of newly forming blood vessels, an event essential for the proliferation of tumors. Nevertheless, it was recently reported, that melanoma cells could form web-like patterns of blood vessels even in the absence of endothelial cells (1999, Science 285, 14), implying that tumors might be able to circumvent some anti-angiogenic drugs which are only effective in the presence of endothelial tissue. Numerous molecules stimulate endothelial proliferation, migration and assembly, including VEGF, Ang1 and bFGF, and are vital survival factors. VEGF (Vascular Endothelial Growth Factor) has been identified as a selective angiogenic growth factor that can stimulate endothelial cell mitogenesis. VEGF, in particular, is thought to be a major mediator of angiogenesis in a primary tumor and in ischemic ocular diseases. VEGF is a homodimer (MW : 46.000) that is an endothelial cell- specific angiogenic (Ferrara et al., 1992, Endocrin. Rev., 13,18) and vasopermeability factor (Senger et al., 1986, Cancer Res., 465629) that binds to high- affinity membrane-bound receptors with tyrosine kinase activity (Jakeman et al., 1992, J. Clin. Invest., 89, 244). Human tumor biopsies exhibit enhanced expression of VEGF mRNAs by malignant cells and VEGF receptor mRNAs in adjacent endothelial cells. VEGF expression appears to be greatest in regions of tumors adjacent to vascular areas of necrosis, (for review see Thomas et al., 1996, J* Biol. Chem. 271(2), 603; Folkman, 1995, Nature Medicine 1, 27). WO 97/45447 has implicated the αvβ5 integrin in neovascularization, particularly, that induced by VEGF, EGF and TGF- α, and discloses that αvβ5 antagonist can inhibit VEGF promoted angiogenesis. Effective anti-tumor therapies may also utilize targeting VEGF receptor for inhibition of angiogenesis using monoclonal antibodies. (Witte et a!., 1998, Cancer Metastasis Rev. 17(2), 155). MAb DC-101 is known to inhibit angiogenesis of tumor cells. As summarized above it is evident that EGF, VEGF and integrins αvβ3 and αvβ5 and their receptors are basically involved in tumor proliferation and tumor angiogenesis, and that effective inhibitors, especially monoclonal antibodies, directed to EGF receptor and/or VEGF receptor and/or integrin receptors or any other protein tyrosine kinase receptors are principally suitable candidates for tumor therapy. Monoclonal antibodies which can specifically recognize their antigen epitopes on the relevant receptors, are of special interest However, the use of such antibodies, which were successful in vitro and in animal models, have not shown satisfying efficacy in patients as mono-drug therapy. Similar results were obtained when other anti-angiogenic or EGF receptor antagonists than antibodies were used in clinical trials. It seems, that tumors, if some specific sites are blocked, may use other cell surface molecules to compensate for said original blocking. Thus, tumors do not really shrink during various anti-angiogenic or anti- proliferative therapies. For these reasons, combination therapies were proposed to circumvent this problem using monoclonal antibodies together with cytotoxic or chemotherapeutic agents or in combination with radiotherapy. Indeed, clinical trials have shown that these combination therapies are more efficient than the corresponding mono-administrations. Thus, for example, antibody-cytokine fusion protein therapies have been described which promote immune response-mediated inhibition of established tumors such as carcinoma metastases. For example, the cytokine interleukin 2 (IL-2) has been fused to specific monoclonal antibodies KS1/4 and ch14.18 directed to the tumor associated antigens epithelial cell adhesion molecule (Ep-CAM, KSA, KS1/4 antigen) or the disialoganglioside GD, respectively, to form the fusion proteins ch14.18-IL-2 and KS1/4-IL-2, respectively (US 5,650,150). Another clinical approach is based on the administration of monclonal antibody c225 in combination with Herceptin® (Ye et al, 1999, I.e.). Furthermore, the combination of anti-EGF receptor antibodies together with anti-neoplastic agents, such as cisplatin or doxorubicin, was disclosed in EP 0667 165 (A1) and US 6,217,866); a similar combination, especially a combination of Herceptin® with cisplatin and other cytotoxic factors, was described in Genentech's US 5,770,195. Synergy effects between an anti-angiogenic integrin Ov antagonist and above-mentioned antibody-cytokine fusion proteins were observed in tumor metastases (Lode et aL 1999, Proc. Natl. Acad. Sci. 96,1591, WO 00/47228). Methods of using integrin antagonists together with anti- neoplastic agents were recently claimed in WO 00/38665. Recently, it was found that a combination of gemcitabine with specific monoclonal antibody DC-101, which inhibits angiogenesis, increased the anti-tumor effect in pancreatic cancer of mice compared with gemcitabine alone. DE 198 42415 discloses the combination of a specific cyclic RGD peptide as integrin inhibitor with specific anti-angiogenesis agents. Other approaches suggest the administration of EGF receptor blocking agents, antibodies included, or integrin antagonists combined with radiation or radiotherapy, respectively (e.g. WO 99/60023, WO 00/0038715). Nevertheless, although various combinations therapies are under investigation and in clinical trials, the outcome of these therapies are not fruitful enough. Therefore, it is a need to develop further combinations which can show increased efficacy and reduced side-effects. SUMMARY OF THE INVENTION: The present inventions describes for the first time a novel pharmaceutical treatment which is based on the new concept in tumor therapy to administer to an individual in a therapeutically effective amount an agent that blocks or inhibits a receptor tyrosine kinase, preferably an ErbB receptor and more preferably an EGF receptor together with an anti-angiogenic agent. Optionally the composition according to this invention may comprise further therapeutically active compounds, preferably selected from the group consisting of cytotoxic agents, chemotherapeutic agents and other pharmacologically active compounds which may enhance the efficacy of said agents or reduce the side effects of said agents. Thus, the invention relates to pharmaceutical compositions comprising as preferred ErbB receptor antagonists an anti-EGFR (ErbB1 / Her 1) antibody and as anti- angiogenic agent an inhibitor or antagonist of any of the αvβ3, αvβ5 or αvβ6 integrin receptors, preferably an RGD containing linear or cyclic peptide. Especially, the inventions relates, as a preferred embodiment, to a specific combination therapy comprising anti-EGFR or anti-Her2 antibodies, such as humanized monoclonal antibody 425 (h425, EMD 72000), chimeric monoclonal antibody 225 (c225) or Herceptin® together with preferably RGD-containing integrin inhibitors, most preferably with the cyclic peptide cyclo-(Arg-Gly-Asp-DPhe-NMe-Val), optionally together with a chemotherapeutic compound. According to this invention said therapeutically active agents may also be provided by means of a pharmaceutical kit comprising a package comprising one or more receptor tyrosine kinase antagonists, one or more anti-angiogenic agents, and optionally, one or more cytotoxic / chemotherapeutic agents in single packages or in separate containers. The therapy with this combinations may include optionally treatment with radiation. However, the invention relates, furthermore, to a combination therapy comprising the administration of only one (fusion) molecule, having anti-receptor tyrosine kinase, preferably anti-ErbB receptor activity and anti-angiogenic activity, optionally together with one or more cytotoxic / chemotherapeutic agents. An example is an anti-EGFR antibody, such as h425 or c225 as described above and below, which is fused at the C-terminal of its Fc portion to an anti-hormonal agent by known recombinant or chemical methods. A further example is a bispecific antibody, whereinone specificity is directed to an nuclear hormone receptor and the other one is directed to the EGF receptor. Principally, the administration can be accompanied by radiation therapy, wherein radiation treatment can be done substantially concurrently or before or after the drug administration. The administration of the different agents of the combination therapy according to the invention can also be achieved substantially concurrently or sequentially. Tumors, bearing receptors on their cell surfaces involved in the development of the blood vessels of the tumor, may be successfully treated by the combination therapy of this invention. It is known that tumors elicit alternative routes for their development and growth. If one route is blocked they often have the capability to switch to another route by expressing and using other receptors and signaling pathways. Therefore, the pharmaceutical combinations of the present invention may block several of such possible development strategies of the tumor and provide consequently various benefits. The combinations according to the present invention are useful in treating and preventing tumors, tumor-like and neoplasia disorders and tumor metastases, which develop and grow by activation of their relevant hormone receptors which are present on the surface of the tumor cells. Preferably, the different combined agents of the present invention are administered in combination at a low dose, that is, at a dose lower than has been conventionally used in clinical situations. A benefit of lowering the dose of the compounds, compositions, agents and therapies of the present invention administered to an individual includes a decrease in the incidence of adverse effects associated with higher dosages. For example, by the lowering the dosage of an agent described above and below, a reduction in the frequency and the severity of nausea and vomiting will result when compared to that observed at higher dosages. By lowering the incidence of adverse effects, an improvement in the quality of life of a cancer patient is contemplated. Further benefits of lowering the incidence of adverse effects include an improvement in patient compliance, a reduction in the number of hospitalizations needed for the treatment of adverse effects, and a reduction in the administration of analgesic agents needed to treat pain associated with the adverse effects. Alternatively, the methods and combination of the present invention can also maximize the therapeutic effect at higher doses. Tumors, bearing (over-expressed) ErbB receptors, preferably ErbB1 (Her1, EGFR) of ErbB2 (Her 2) receptors on their cell surfaces, may be successfully treated by the combinations according to the inventions. The combinations within the pharmaceutical treatment according to the inventions show an astonishing synergetic effect. In administering the combination of drugs real tumor shrinking and disintegration could be observed during clinical studies while no significant adverse drug reactions were detectable. Above all, the three-drug combinations (receptor tyrosine kinase, preferably ErbB receptor blocking agent plus anti-angiogenic agent plus chemotherapeutic agent) show superior efficacy. However, whether a chemotherapeutic drug is synergistically effective or not depends on the drug itself, the receptor tyrosine kinase, preferably ErbB receptor antagonist and the tumor cell that is treated with said agents, and must be usually checked case by case. In detail the invention refers to: • a pharmaceutical composition comprising an agent or agents having (i) at least one receptor tyrosine kinase blocking / inhibiting specificity and (ii) at least one angiogenesis blocking / inhibiting specificity, wherein said agent or agents is / are not a cytokine immunoconjugate, optionally together with a pharmaceutically acceptable carrier, diluent or recipient; • as a first alternative, a pharmaceutical comprising (i) at least one agent having a receptor tyrosine kinase blocking specificity, and (ii) at least one agent having an angiogenesis inhibiting specificity; • as a second alternative, a pharmaceutical composition, comprising an agent having a receptor tyrosine kinase blocking specificity as well as an angiogenesis inhibiting specificity. • corresponding compositions further comprising at least one cytotoxic, preferably chemotherapeutic agent; • in more detail, a pharmaceutical composition, wherein said agent (i) has a ErbB receptor blocking / inhibiting specificity; • a corresponding pharmaceutical composition, wherein the ErbB receptor specificity of said agent is related to the EGF receptor (ErbB1/Her1) or the ErbB2/Her2 receptor; • in more detail, a pharmaceutical composition, wherein said agent is an antibody or a functionally intact derivative thereof, comprising a binding site which binds to an epitope of the ErbB1 (Her1) or Erb2 (Her2) receptor; • as preferred embodiment, a pharmaceutical composition, wherein said antibody or functionally intact derivative thereof is selected from the group: humanized monoclonal antibody 425 (h425) chimeric monoclonal antibody 225 (c225) humanized monoclonal antibody Her 2, the corresponding humanized, chimeric or de-immunized functionally intact dervatives included; • a corresponding pharmaceutical composition, wherein said angiogenesis inhibiting agent is an αvβ3, αvβ5 or anαvβ6 integrin inhibitor; • a corresponding pharmaceutical composition, wherein said integrin inhibitor is an RGD-containing linear or cyclic peptide, preferably cyclo(Arg-Gly-Asp- DPhe-NMeVal); • as a specific embodiment, a pharmaceutical composition, wherein said antibody or functionally intact derivative thereof is humanized monoclonal antibody 425 (h425) or chimeric monoclonal antibody 225 (c225), de- immunized forms included, and said integrin inhibitor is cyclo(Arg-Gly-Asp- DPhe-NMeVal), optionally comprising, optionally in separate containers or packages, a chemotherapeutic agent which is selected from any of the compounds of the group: cisplatin, doxorubicin, gemcitabine, docetaxel, paclitaxel, bleomycin; • a corresponding pharmaceutical composition, wherein said integrin inhibitor is an antibody or a functionally intact derivative thereof, comprising a binding site which binds to an epitope of an integrin receptor, preferably selected from the group of antibodies: LM609, P1F6,17E6,14D9.F8, humanized, chimeric and de-immunized versions thereof included; • a pharmaceutical composition, wherein one of said agents is a bispecific antibody or a heteroantibody molecule comprising a first binding site that binds to an epitope of a receptor tyrosine kinase, preferably ErbB receptor, and a second binding site that binds to an epitope of an angiogenesis receptor, preferably an integrin receptor; • a specific corresponding pharmaceutical composition, wherein said monoclonal antibodies are selected from h425, c225 or Her 2, and from the monoclonal antibodies LM609, P1F6,17E6 and 14D9.F8; • a pharmaceutical composition, wherein one of said agents is an immunoconjugate consisting of an antibody or antibody fragment, bearing one of said blocking specificities, and a non-immunological molecule, fused to the antibody or antibody fragment bearing the other specificity; • a corresponding pharmaceutical composition, wherein the antibody portion or fragment thereof comprises a binding site that binds to an epitope of an ErbB receptor, preferably an EGF receptor (Her 1), and the fused non-immunological molecule comprises a binding site that binds to an epitope of an integrin receptor; • a specific pharmaceutical composition thereof, wherein said antibody portion which binds to an epitope of an ErbB receptor is selected from monoclonal antibodies h425, c225 or Her 2, and said non-imunological portion which binds to an epitope of an integrin receptor is cyclo(Arg-Gly-Asp-DPhe-NMeVal); • a pharmaceutical kit comprising (i) a package comprising at least one receptor tyrosine kinase inhibiting, preferably an ErbB receptor blocking agent, and (ii) a package comprising at least one angiogenesis inhibiting agent, preferably an αvβ3, αvβ5 or an αvβ6 integrin receptor inhibiting agent, more preferably an RGD-containing linear or cyclic peptide, especially cyclo(Arg-Gly-Asp-DPhe- NMeVal); optionally further comprising a package comprising a cytotoxic agent; • a corresponding pharmaceutical kit, wherein said ErbB receptor blocking agent is an antibody or a functionally intact derivative thereof, having a binding site that binds to an epitope of said receptor; said antibody is preferably selected from the group of antibodies: humanized monoclonal antibody 425 (h425), chimeric monoclonal antibody 225 (c225) or humanized monoclonal antibody Her 2; • a pharmaceutical kit, wherein said angiogenesis inhibiting agent is an antibody or an active derivative thereof, preferably selected from the group of antibodies: LM609, P1H6,17E6 and 14D9.F8; • as specific embodiment of the invention, a specific pharmaceutical kit, comprising (i) a package comprising humanized monoclonal antibody 425 (h425), chimeric monoclonal antibody 225 (c225), or a functionally intact derivative thereof, and (ii) a package comprising cyclo(Arg-Gly-Asp-DPhe-NMeVal), optionally comprising a chemotherapeutic agent which is selected from any of the compounds of the group: cisplatin, doxorubicin, gemcitabine, docetaxel, paclitaxel, bleomycin; • the use of a pharmaceutical composition or a pharmaceutical kit as defined above, below and in the claims, for the manufacture of a medicament to treat tumors and tumor metastases; • a pharmaceutical treatment or method for treating tumors or tumor metastases in a patient comprising administering to said patient a therapeutically effective amount of an agent or agents having (i) at least one receptor tyrosine kinase blocking specificity and (ii) at least one angiogenesis inhibiting specificity, wherein said agent or agents is / are not a cytokine immunoconjugate, optionally together with a cytotoxic, preferably chemotherapeutic agent, and wherein, preferably, said agent (i) is an antibody or a functionally intact derivative thereof, comprising a binding site which binds to an epitope of the ErbB receptor, preferably, ErbB1(Her1) or Erb2(Her2) receptor, and said agent (ii) is a αvβ3, αvβ5 or an αvβ6 integrin inhibitor or a VEGF receptor blocking agent; and finally • a corresponding method, wherein said antibody directed to the ErbB receptor is selected from the group: humanized monoclonal antibody 425 (h425), chimeric monoclonal antibody 225 (c225) or humanized monoclonal antibody Her 2, and anti-angiogenic agent is cycio(Arg-Gly-Asp-DPhe-NMeVal), optionally together with a cytotoxic drug selected from the group: cisplatin, doxorubicin, gemcitabine, docetaxel, paclitaxel, bleomycin. The pharmaceutical treatment using the pharmaceutical compositions and kits according to the invention may be accompanied, concurrently or sequentially, by a radiation therapy. Principally, four different combinations of pharmaceutical compositions can be distinguished according to the invention: (i) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity combined with an agent comprising at least one anti-angiogenic activity (two-drug combination); (ii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity combined with an agent comprising at least one anti-angiogenic activity and combined with at least one chemotherapeutic agent (three-drug combination); (iii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity as well as at least one anti-angiogenic activity combined in one molecule (one-drug combination having two-drug activity); (iv) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity as well as at least one anti-angiogenic activity combined in one molecule, combined with at least one chemotherapeutic agent (two- drug combination having three-drug activity); The agents can be administered concurrently or sequentially in any of said cases. According to the above-said, the methods of the invention comprise, in principal, the following combinations of administration: (i) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity combined with an agent comprising at least one anti-angiogenic activity (two-drug administration); (ii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity combined with an agent comprising at least one anti-angiogenic activity (two- drug administration) and radiotherapy; (iii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity combined with an agent comprising at least one anti-angiogenic activity combined with at least one chemotherapeutic agent (three- drug administration); (iv) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity combined with an agent comprising at least one anti-angiogenic activity combined with at least one chemotherapeutic agent (three- drug administration) and radiotherapy; (v) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity as well as at least one anti-angiogenic activity combined in one molecule (one-drug administration having "two-drug activity"); (vi) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity as well as at least one anti-angiogenic activity combined in one molecule (one-drug administration having "two-drug activity") and radiotherapy; (vii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity as well as at least one anti-angiogenic activity combined in one molecule combined with at least one chemotherapeutic agent (two- drug administration having "three-drug activity"); (viii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB receptor blocking activity / specificity as well as at least one anti-angiogenic activity combined in one molecule combined with at least one chemotherapeutic agent (two- drug administration having "three-drug activity") and radiotherapy. The pharmaceutical combinations and methods of the present invention provide various benefits. The combinations according to the present invention are useful in treating and preventing tumors, tumor-like and neoplasia disorders. Preferably, the different combined agents of the present invention are administered in combination at a low dose, that is, at a dose lower than has been conventionally used in clinical situations. A benefit of lowering the dose of the compounds, compositions, agents and therapies of the present invention administered to a mammal includes a decrease in the incidence of adverse effects associated with higher dosages. For example, by the lowering the dosage of a chemotherapeutic agent such as methotrexate, doxorubicin, gemcitabine, docetaxel, paclitaxel, bleomycin or cisplatin, a reduction in the frequency and the severity of nausea and vomiting will result when compared to that observed at higher dosages. Similar benefits are contemplated for the compounds, compositions, agents and therapies in combination with the integrin antagonists of the present invention. By lowering the incidence of adverse effects, an improvement in the quality of life of a cancer patient is contemplated. Further benefits of lowering the incidence of adverse effects include an improvement in patient compliance, a reduction in the number of hospitalizations needed for the treatment of adverse effects, and a reduction in the administration of analgesic agents needed to treat pain associated with the adverse effects. Alternatively, the methods and combination of the present invention can also maximize the therapeutic effect at higher doses. DETAILED DESCRIPTION OF THE INVENTION If not otherwise pointed out the terms and phrases used in this invention have the meanings and definitions as given below. Moreover, these definitions and meanings describe the invention in more detail, preferred embodiments included. A "receptor" or "receptor molecule" is a soluble or membrane bound / associated protein or glycoprotein comprising one or more domains to which a ligand binds to form a receptor-ligand complex. By binding the ligand, which may be an agonist or an antagonist the receptor is activated or inactivated and may initiate or block pathway signaling. By" ligand" or "receptor ligand" is meant a natural or synthetic compound which binds a receptor molecule to form a receptor-ligand complex. The term ligand includes agonists, antagonists, and compounds with partial agonist/antagonist action. An "agonist" or "receptor agonist" is a natural or synthetic compound which binds the receptor to form a receptor-agonist complex by activating said receptor and receptor-agonist complex, respectively, initiating a pathway signaling and further biological processes. By "antagonist" or "receptor antagonist" is meant a natural or synthetic compound that has a biological effect opposite to that of an agonist. An antagonist binds the receptor and blocks the action of a receptor agonist by competing with the agonist for receptor. An antagonist is defined by its ability to block the actions of an agonist. A receptor antagonist may be also an antibody or an immunotherapeutically effective fragment thereof. Preferred antagonists according to the present invention are cited and discussed below. An "ErbB receptor" is a receptor protein tyrosine kinase which belongs to the ErbB receptor family and includes EGFR(ErbBl), ErbB2, ErbB3 and ErbB4 receptors and other members of this family to be identified in the future. The ErbB receptor will generally comprise an extracellular domain, which may bind an ErbB ligand; a lipophilic transmembrane domain; a conserved intracellular tyrosine kinase domain; and a carboxyl-terminal signaling domain harboring several tyrosine residues which can be phosphorylated. The ErbB receptor may be a "native sequence" ErbB receptor or an "amino acid sequence variant" thereof. Preferably the ErbB receptor is native sequence human ErbB receptor. ErbB1 refers to the gene encoding the EGFR protein product. Mostly preferred is the EGF receptor (Her 1). The expressions "ErbB1" and "Her 1" are used interchangeably herein and refer to human Her 1 protein. The expressions "ErbB2" and "Her 2" are used interchangeably herein and refer to human Her 2 protein. ErbB1 receptors (EGFR) are preferred according to this invention "ErbB ligand" is a polypeptide which binds to and/or activates an ErbB receptor. ErbB ligands which bind EGFR include EGF, TGF-a, amphiregulin, betacellulin, HB- EGF and epiregulin. The term "tyrosine kinase antagonist/inhibitor" refers to natural or synthetic agents that are enabled to inhibit or block tyrosine kinases, receptor tyrosine kinases included, which are of specific interest of this invention. Thus, the term includes "ErbB receptor antagonists/inhibitors', which are defined below in more detail. With exception of these antagonists, preferably anti-ErbB receptor antibodies additionally suitable tyrosine kinase antagonists of the invention are chemical compounds which have shown efficacy in mono- drug therapy for, e.g., breast and prostate cancer. Suitable indolocarbazole-type tyrosine kinase inhibitors can be obtained using information found in documents such as US patents 5,516,771; 5,654,427; 5,461,146; 5,650,407. US patents 5,475,110; 5,591,855; 5,594,-009 and WO 96/11933 disclose pyrrolocarbazole-type tyrosine kinase inhibitors and prostate cancer. Preferably, the dosage of the chemical tyrosine kinase inhibitors as defined above is from 1 pg/kg to 1 g/kg of body weight per day. More preferably, the dosage of tyrosine kinase inhibitors is from 0.01 mg/kg to 100 mg/kg of body weight per day. The term 'ErbB receptor antagonist / inhibitor" refers to a natural or synthetic molecule which binds and blocks or inhibits the ErbB receptor, and is therefore a member of the "(receptor) tyrosine kinase antagonist/inhibitor" family. Thus, by blocking the receptor the antagonist prevents binding of the ErbB ligand (agonist) and activation of the agonist/ligand receptor complex. ErbB antagonists may be directed to Her 1 (or EGFR / Her 1) or Her 2. Preferred antagonists of the invention are directed to the EGF receptor (EGFR, Her 1). The ErbB receptor antagonist may be an antibody or an immunotherapeutically effective fragment thereof or non- immunobiological molecules, such as a peptide, polypeptide protein. Chemical molecules are also included, however, anti-EGFR antibodies and anti-Her 2 antibodies are the preferred antagonists according to the invention. Preferred antibodies of the invention are anti-Herl and anti-Her2 antibodies, more preferably anti-Herl antibodies. Preferred anti-Herl antibodies are MAb 425, preferably humanized MAb 425 (hMAb 425, US 5,558,864; EP 0531 472) and chimeric MAb 225 (cMAb 225, US 4,943,533 and EP 0359 282). Most preferred is monoclonal antibody h425, which has shown in mono-drug therapy high efficacy combined with reduced adverse and side effects,.Most preferred anti-Her2 antibody is HERCEPTIN® commercialized by Genentech/Roche. Efficacious EGF receptor antagonists according to the invention may be also other natural or synthetic chemical compounds. Some examples of preferred molecules of this category include organic compounds, organometallic compounds, salts of organic and organometallic compounds. Efficacious ErbB receptor antagonists according to the invention may be also small molecules. Small molecules of the invention are not biological molecules as defined above having a molecular weight of approximately not greater than 400. Preferably, they have no protein or peptide structure, and are most preferably synthetically produced chemical compounds. Some examples of preferred small molecules include organic compounds, organometallic compounds, salts of organic and organometallic compounds. Numerous small molecules have been described as being useful to inhibit EGF receptor and / or Her 2 receptor. Examples are: styryl substituted heteroaryl compounds (US 5,656,655); bis mono and/or bicyclic aryl heteroaryl, carbocyctic, and heterocarbocyclic compounds (US 5,646,153); tricyclic pyrimidine compounds (US 5,679,683); quinazoline derivatives having receptor tyrosine kinase inhibitory activity (US 5,616,582); heteroarylethenediyl or heteroarylethenediylaryl compounds (US 5,196,446); a compound designated as 6-(2,6-dichlorophenyl)-2-(4-(2-diethyl- aminoethoxy) phenylamino)-8-methyl-8H-pyrido(2,3)-5-pyrirnidin-7-one (Panek, et al., 1997, J. Pharmacol. Exp. Therap. 283,1433) inhibiting EGFR, PDGFR, and FGFR families of receptors. An "anti-angiogenic agent' refers to a natural or synthetic compound which blocks, or interferes with to some degree, the development of blood vessels. The anti- angiogenic molecule may, for instance, be a biological molecule that binds to and blocks an angiogenic growth factor or growth factor receptor. The preferred anti- angiogenic molecule herein binds to an receptor, preferably to an integrin receptor or to VEGF receptor. The term includes according to the invention also a prodrug of said angiogenic agent. There are a lot of molecules having different structure and origin which elicit anti-agiogenic properties. Most relevant classes of angiogenesis inhibitong or blocking agents which are suitable in this invention, are, for example: (i) anti-mitotics such as flurouracil, mytomycin-C, taxol; (ii) estrogen metabo!ites_such as 2-methoxyestradiol; (iii) matrix metalloproteinase (MMP) inhibitors, which inhibit zinc metalloproteinases (metalloproteases) (e.g. betimastat, BB16, TIMPs, minocycline, GM6001, or those described in "Inhibition of Matrix Metalloproteinases: Therapeutic Applications" (Golub, Annals of the New York Academy of Science, Vol. 878a; Greenwald, Zucker (Eds.), 1999); (iv) anti-angiogenic multi-functional agents and factors such as IFNα (US 4,530,901; US 4,503,035; 5,231,176); angiostatin and plasminogen fragments (e.g. kringle 1-4, kringle 5, kringle 1-3 (O'Reilly, M. S. et al., Cell (Cambridge, Mass.) 79(2): 315-328, 1994; Cao et al., J. Biol. Chem. 271: 29461-29467, 1996; Cao et al., J. Biol Chem 272:22924 -22928,1997); endostatin (O'Reilly, M. S. et al., Cell 88(2), 277, 1997 and WO 97/15666), thrombospondin (TSP-1; Frazier,1991. Curr Opin Cell Biol 3(5): 792); platelet factor 4 (PF4); (v) plasminogen activator/urokinase inhibitors; (vi) urokinase receptor antagonists; (vii) heparinases; (viii) fumagillin analogs such as TNP-470: (ix) tyrosine kinase inhibitors such as SUI01 (many of the above and below - mentioned ErbB receptor antagonists (EGFR / Her 2 antagonists) are also tyrosine kinase inhibitors, and may show, therefore anti-EGF receptor blocking activity which results in inhibiting tumor growth, as well as anti-angiogenic activity which results in inhibiting the development of blood vessels and endothelial cells, respectively); (x) suramin and suramin analogs; (xi) angiostatic steroids; (xii) VEGF and bFGF antagonists; (xiii) VEGF receptor antagonists.such as anti-VEGF receptor antibodies (DC-101); (xiv) flk-1 and flt-1 antagonists; (xv) cyclooxxygenase-ll inhibitors such as COX-II; (xvi) integrin antagonists and integrin receptor antagonists such as av antagonists and αv receptor antagonists, for example, anti-αv receptor antibodies and RGD peptides. Integrin (receptor) antagonists are preferred according to this invention. The term "integrin antagonists / inhibitors" or "integrin receptor antagonists / inhibitors" refers to a natural or synthetic molecule that blocks and inhibit an integrin receptor. In some cases, the term includes antagonists directed to the ligands of said integrin receptors (such as for 0763." vitronectin, fibrin, fibrinogen, von Willebrand's factor, thrombospondin, laminin; for αvβ5: vitronectin; for αvβ1: fibronectin and vitronectin; for αvβ6: fibronectin). Antagonists directed to the integrin receptors are preferred according to the invention. Integrin (receptor) antagonists may be natural or synthetic peptides, non-peptides, peptidomimetica, immunoglobulins, such as antibodies or functional fragments thereof, or immunoconjugates (fusion proteins). Preferred integrin inhibitors of the invention are directed to receptor of αv integrins (e.g. αvβ3, αvβ5, αvβ6 and sub-classes). Preferred integrin inhibitors are αv antagonists, and in particular αvβ3 antagonists. Preferred αv antagonists according to the invention are RGD peptides, peptidomimetic (non-peptide) antagonists and anti- integrin receptor antibodies such as antibodies blocking αv receptors. Exemplary, non-immunological αvβ3 antagonists are described in the teachings of US 5,753,230 and US 5,766,591. Preferred antagonists are linear and cyclic RGD- containing peptides. Cyclic peptides are, as a rule, more stable and elicit an enhanced serum half-life. The most preferred integrin antagonist of the invention is, however, cyclo-(Arg-Gly-Asp-DPhe-NMeVal) (EMD 121974, Cilengitide®, Merck KgaA, Germany; EP 0770 622) which is efficacious in blocking the integrin receptors αvβ3, αvβ1, αvβ6, αvβ8, α11bβ3. Suitable peptidyl as well as peptidomimetic (non- peptide) antagonists of the αvβ3/ αvβ5 / αvβ6 integrin receptor have been described both in the scientific and patent literature. For example, reference is made to Hoekstra and Poulter, 1998, Curr. Med. Chem. 5,195; WO 95/32710; WO 95/37655; WO 97/01540; WO 97/37655; WO 97/45137; WO 97/41844; WO 98/08840; WO 98/18460; WO 98/18461; WO 98/25892; WO 98/31359; WO 98/30542; WO 99/15506; WO 99/15507; WO 99/31061; WO 00/06169; EP 0853 084; EP 0854 140; EP 0854 145; US 5,780,426; and US 6,048,861. Patents that disclose benzazepine, as well as related benzodiazepine and benzocycloheptene avB3 integrin receptor antagonists, which are also suitable for the use in this invention, include WO 96/00574, WO 96/00730, WO 96/06087, WO 96/26190, WO 97/24119, WO 97/24122, WO 97/24124, WO 98/15278, WO 99/05107, WO 99/06049, WO 99/15170, WO 99/15178, WO 97/34865, WO 97/01540, WO 98/30542, WO 99/11626, and WO 99/15508. Other integrin receptor antagonists featuring backbone conformational ring constraints have been described in WO 98/08840; WO 99/30709; WO 99/30713; WO 99/31099; WO 00/09503; US 5,919,792; US 5,925,655; US 5,981,546; and US 6,017,926. In US 6,048,861 and WO 00/72801 a series of nonanoic acid derivatives which are potent αvβ3 integrin receptor antagonists were disclosed. Other chemical small molecule integrin antagonists (mostly vitronectin antagonists) are described in WO 00/38665. Other αvβ3 receptor antagonists have been shown to be effective in inhibiting angiogenesis. For example, synthetic receptor antagonists such as (S)-10.11-Dihydro-3-[3-(pyridin-2-ylamino)-1-propyloxy]-5H- dibenzo[ a,d]cycloheptene-10-acetic acid (known as SB-265123) have been tested in a variety of mammalian model systems. (Keenan et al., 1998, Bioorg. Med. Chem. Lett. 8(22), 3171; Ward et al., 1999, Drug Metab. Dispos. 27(11),1232). Assays for the identification of integrin antagonists suitable for use as an antagonist are described, e.g. by Smith et al., 1990, J. Biol. Chem. 265,12267, and In the referenced patent literature. Anti-integrin receptor antibodies are also well known. Suitable anti- integrin (e.g. αvβ3, αvβ5, αvβ6) monoclonal antibodies can be modified to encompasses antigen binding fragments thereof, including F(ab)2, Fab, and engineered Fv or single-chain antibody. One suitable and preferably used monoclonal antibody directed against integrin receptor αvβ3 is identified as LM609 (Brooks et al., 1994, Cell 79, 1157; ATCC HB 9537). A potent specific anti-OvB5 antibody, P1F6, is disclosed in WO 97/45447, which is also preferred according to this invention. A further suitable αvβ6 selective antibody is MAb 14D9.F8 (WO 99/37683, DSM ACC2331, Merck KGaA, Germany) as well as MAb 17.E6 (EP 0719 859, DSM ACC2160, Merck KGaA) which is selectively directed to the αv- chain of integrin receptors. Another suitable anti-integrin antibody is the commercialized Vitraxin ®. The term "antibody" or "immunoglobulin" herein is used in the broadest sense and specifically covers intact monoclonal antibodies, polyclonal antibodies, multispecific antibodies (e.g. bispecific antibodies) formed from at least two intact antibodies, and antibody fragments, so long as they exhibit the desired biological activity. The term generally includes heteroantibodies which are composed of two or more antibodies or fragments thereof of different binding specificity which are linked together. Depending on the amino acid sequence of their constant regions, intact antibodies can be assigned to different "antibody (Immunoglobulin) classes". There are five major classes of intact antibodies: IgA, IgD, IgE, IgG, and IgM, and several of these may be further divided into "subclasses" (isotypes), e.g., IgGl, lgG2, lgG3, lgG4, IgA, and lgA2. The heavy-chain conscant domains that correspond to the different classes of antibodies are called , δ, ε, γ and μ respectively. Preferred major class for antibodies according to the invention is IgG, in more detail lgG1 and lgG2. Antibodies are usually glycoproteins having a molecular weight of about 150,000, composed of two identical light (L) chains and two identical heavy (H) chains. Each light chain is linked to a heavy chain by one covalent disulfide bond, while the number of disulfide linkages varies among the heavy chains of different immunoglobulin isotypes. Each heavy and light chain also has regularly spaced intra-chain disulfide bridges. Each heavy chain has at one end a variable domain (VH) followed by a number of constant domains. The variable regions comprise hypervariable regions or "CDR" regions, which contain the antigen binding site and are responsible for the specificity of the antibody, and the "FR" regions, which are important with respect to the affinity / avidity of the antibody. The hypervariable region generally comprises amino acid residues from a "complementarity determining region" or "CDR" (e.g. residues 24-34 (L1), 50-56 (L2) and 89-97 (L3) in the light chain variable domain and 31-35 (HI), 50-65 (H2) and 95-102 (H3) in the heavy chain variable domain; and/or those residues from a "hypervariable loop" (e.g. residues 26-32 (L1 ), 50-52 (L2) and 91-96 (L3) in the light chain variable domain and 26-32 (H1), 53-55 (H2) and 96- 101 (H3) in the heavy chain variable domain; Chothia and Lesk J. Mot. Biol. 196:901- 917 (1987)).The TR" residues (frame work region) are those variable domain residues other than the hypervariable region residues as herein defined. Each light chain has a variable domain at one end (VL) and a constant domain at its other end. The constant domain of the light chain is aligned with the first constant domain of the heavy chain, and the light-chain variable domain is aligned with the variable domain of the heavy chain. Particular amino acid residues are believed to form an interface between the light chain and heavy chain variable domains. The "light chains" of antibodies from any vertebrate species can be assigned to one of two clearly distinct types, called kappa (K) and lambda (X), based on the amino acid sequences of their constant domains. The term "monoclonal antibody" as used herein refers to an antibody obtained from a population of substantially homogeneous antibodies, i.e., the individual antibodies comprising the population are identical except for possible naturally occurring mutations that may be present in minor amounts. Monoclonal antibodies are highly specific, being directed against a single antigenic site. Furthermore, in contrast to polyclonal antibody preparations which include different antibodies directed against different determinants (epitopes), each monoclonal antibody is directed against a single determinant on the antigen. In addition to their specificity, the monoclonal antibodies are advantageous in that they may be synthesized uncontaminated by other antibodies. Methods for making monoclonal antibodies include the hybridoma method described by Kohler and Miistein (1975, Nature 256, 495) and in "Monoclonal Antibody Technology, The Production and Characterization of Rodent and Human Hybridomas" (1985, Burdon et al., Eds, Laboratory Techniques in Biochemistry and Molecular Biology, Volume 13, Elsevier Science Publishers, Amsterdam), or may be made by well known recombinant DNA methods (see, e.g., US 4,816,567). Monoclonal antibodies may also be isolated from phage antibody libraries using the techniques described in Clackson et al., Nature, 352:624-628 (1991) and Marks etal., J. Mol. Biol., 222:58, 1-597(1991), for example. The term "chimeric antibody" means antibodies in which a portion of the heavy and/or light chain is identical with or homologous to corresponding sequences in antibodies derived from a particular species or belonging to a particular antibody class or subclass, while the remainder of the chain(s) is identical with or homologous to corresponding sequences in antibodies derived from another species or belonging to another antibody class or subclass, as well as fragments of such antibodies, so long as they exhibit the desired biological activity (e.g.: US 4,816,567; Morrison et al., Proc. Nat. Acad. Sci. USA, 81:6851-6855 (1984)). Methods for making chimeric and humanized antibodies are also known in the art. For example, methods for making chimeric antibodies include those described in patents by Boss (Celltech) and by Cabilly (Genentech) (US 4,816,397; US 4,816,567). "Humanized antibodies" are forms of non-human (e.g., rodent) chimeric antibodies that contain minimal sequence derived from non-human immunoglobulin. For the most part, humanized antibodies are human immunoglobulins (recipient antibody) in which residues from a hypervariable region (CDRs) of the recipient are replaced by residues from a hypervariable region of a non-human species (donor antibody) such as mouse, rat, rabbit or nonhuman primate having the desired specificity, affinity and capacity. In some instances, framework region (FR) residues of the human immunoglobulin are replaced by corresponding non-human residues. Furthermore, humanized antibodies may comprise residues that are not found in the recipient antibody or in the donor antibody. These modifications are made to further refine antibody performance. In general, the humanized antibody will comprise substantially all of at least one, and typically two, variable domains, in which all or substantially all of the hypervariable loops correspond to those of a non-human immunoglobulin and all or substantially all of the FRs are those cf a human immunoglobulin sequence. The humanized antibody optionally also will comprise at least a portion of an immunoglobulin constant region (Fc), typically that of a human immunoglobulin. Methods for making humanized antibodies are described, for example, by Winter (US 5,225,539) and Boss (Celltech, US 4,816,397). "Antibody fragments" comprise a portion of an intact antibody, preferably comprising the antigen-binding or variable region thereof. Examples of antibody fragments include Fab, Fab', F(ab')2, Fv and Fc fragments, diabodies, linear antibodies, single-chain antibody molecules; and multispecific antibodies formed from antibody fragment(s). An "intact" antibody is one which comprises an antigen-binding variable region as well as a light chain constant domain (CL) and heavy chain constant domains, CH1, CH2 and CH3. Preferably, the intact antibody has one or more effector functions. Papain digestion of antibodies produces two identical antigen-binding fragments, called "Fab" fragments, each comprising a single antigen- binding site and a CL and a CH1 region, and a residual "Fc" fragment, whose name reflects its ability to crystallize readily. The "Fc" region of the antibodies comprises, as a rule, a CH2, CH3 and the hinge region of an lgG1 or lgG2 antibody major class. The hinge region is a group of about 15 amino acid residues which combine the CH1 region with the CH2-CH3 region. Pepsin treatment yields an "F(ab')2" fragment that has two antigen-binding sites and is still capable of cross-linking antigen. "Fv" is the minimum antibody fragment which contains a complete antigen-recognition and antigen-binding site. This region consists of a dimer of one heavy chain and one light chain variable domain in tight, non-covalent association. It is in this configuration that the three hypervariable regions (CDRs) of each variable domain interact to define an antigen-binding site on the surface of the VH - VL dimer. Collectively, the six hypervariable regions confer antigen-binding specificity to the antibody. However, even a single variable domain (or half of an Fv comprising only three hypervariable regions specific for an antigen) has the ability to recognize and bind antigen, although at a lower affinity than the entire binding site. The Fab fragment also contains the constant domain of the light chain and the first constant domain (CH1) of the heavy chain." Fab'" fragments differ from Fab fragments by the addition of a few residues at the carboxy terminus of the heavy chain CH1 domain including one or more cysteines from the antibody hinge region. F(ab')2 antibody fragments originally were produced as pairs of Fab' fragments which have hinge cysteines between them. Other chemical couplings of antibody fragments are also known (see e.g. Hermanson, Bioconjugate Techniques, Academic Press, 1996;. US 4,342,566). "Single-chain Fv" or "scFv" antibody fragments comprise the V, and V, domains of antibody, wherein these domains are present in a Single polypeptide chain. Preferably, the Fv polypeptide further comprises a polypeptide linker between the VH and VL domains which enables the scFv to form the desired structure for antigen binding. Single-chain FV antibodies are known, for example, from Pluckthun (The Pharmacology of Monoclonal Antibodies, Vol. 113, Rosenburg and Moore eds., Springer-Verlag, New York, pp. 269-315 (1994)), W093/16185; US 5,571,894; US 5,587,458; Huston et al. (1988, Proc.Natl. Acad. Sci. 85, 5879) or Skerra and Plueckthun (1988, Science 240, 1038). "Bispecific antibodies" are single, divalent antibodies (or immunotherapeutically effective fragments thereof) which have two differently specific antigen binding sites. For example the first antigen binding site is directed to an angiogenesis receptor (e.g. integrin or VEGF receptor), whereas the second antigen binding site is directed to an ErbB receptor (e.g. EGFR or Her 2). Bispecific antibodies can be produced by chemical techniques (see e.g., Kranz et al. (1981) Proc. Natl. Acad. Sci. USA 78, 5807), by "polydoma" techniques (See US 4,474,893) or by recombinant DNA techniques, which all are known per se. Further methods are described in WO 91/00360, WO 92/05793 and WO 96/04305. Bispecific antibodies can also be prepared from single chain antibodies (see e.g., Huston et al. (1988) Proc. Natl. Acad. Sci. 85, 5879; Skerra and Plueckthun (1988) Science 240, 1038). These are analogues of antibody variable regions produced as a single polypeptide chain. To form the bispecific binding agent, the single chain antibodies may be coupled together chemically or by genetic engineering methods known in the art. It is also possible to produce bispecific antibodies according to this invention by using leucine zipper sequences. The sequences employed are derived from the leucine zipper regions of the transcription factors Fos and Jun (Landschulz et al., 1988, Science 240,1759; for review, see Maniatis and Abel, 1989, Nature 341,24). Leucine zippers are specific amino acid sequences about 20-40 residues long with leucine typically occurring at every seventh residue.. Such zipper sequences form amphipathic α-helices, with the leucine residues lined up on the hydrophobic side for dimer formation. Peptides corresponding to the leucine zippers of the Fos and Jun proteins form heterodimers preferentially (O'Shea et al., 1989, Science 245, 646). Zipper containing bispecific antibodies and methods for making them are also disclosed in WO 92/10209 and WO 93/11162. A bispecific antibody according the invention may be an antibody, directed to VEGF receptor and αV33 receptor as discussed above with respect to the antibodies having single specificity. "Heteroantibodies" are two or more antibodies or antibody-binding fragments which are linked together, each of them having a different binding specificity. Heteroantibodies can be prepared by conjugating together two or more antibodies or antibody fragments. Preferred heteroantibodies are comprised of cross-linked Fab/Fab' fragments. A variety of coupling or crosslinking agents can be used to conjugate the antibodies. Examples are protein A, carboiimide, N-succinimidyl-S- acetyl-thioacetate (SATA) and N-succinimidyl-3-(2-pyridyldithio) propionate (SPDP) (see e.g., Karpovsky et al. (1984) J. EXP. Med. 160,1686; Liu et a. (1985) Proc. Natl. Acad. Sci. USA 82, 8648). Other methods include those described by Paulus, Behring Inst. Mitt., No. 78, 118 (1985); Brennan et a. (1985) Science 30 m:81 or Glennie et al. (1987) J. Immunol. 139, 2367. Another method uses o-phenylenedimaleimide (oPDM) for coupling three Fab' fragments (WO 91/03493). Multispecific antibodies are in context of this invention also suitable and can be prepared, for example according to the teaching of WO 94/13804 and WO 98/50431. The term "fusion protein" refers to a natural or synthetic molecule consisting of one ore more proteins or peptides or fragments thereof having different specificity which are fused together optionally by a linker molecule. As specific embodiment the term includes fudsion constructs, wherein at least one protein or peptide is a immunoglubulin or antibody, respectively or parts thereof ("immunoconjugates"). The term "immunoconjugate' refers to an antibody or immunoglobulin respectively, or a immunologically effective fragment thereof, which is fused by covalent linkage to a non-immunologically effective molecule. Preferably this fusion partner is a peptide or a protein, which may be glycosylated. Said non-antibody molecule can be linked to the C-terminal of the constant heavy chains of the antibody or to the N-terminals of the variable light and/or heavy chains. The fusion partners can be linked via a linker molecule, which is, as a rule, a 3 -15 amino acid residues containing peptide. Immunoconjugates according to the invention consist of an immunoglobulin or immunotherapeutically effective fragment thereof, directed to a receptor tyrosine kinase, preferably an ErbB (ErbB1/ErbB2) receptor and an integrin antagonistic peptide, or an angiogenic receptor, preferably an integrin or VEGF receptor and TNFα or a fusion protein consisting essentially of TNFα and IFNγ or another suitable cytokine, which is linked with its N-terminal to the C-terminal of said immunoglobulin, preferably the Fc portion thereof. The term includes also corresponding fusion constructs comprising bi- or multi-specific immunoglobulins (antibodies) or fragments thereof. The term "functionally intact derivative" means according to the understanding of this invention a fragment or portion, modification, variant, homologue or a de- immunized form (a modification, wherein epitopes, which are responsible for immune responses, are removed) of a compound, peptide, protein, antibody (immunoglobulin), immunconjugate, etc., that has principally the same biological and / or therapeutic function as compared with the original compound, peptide, protein, antibody (immunoglobulin), immunconjugate, etc. However, the term includes also such derivatives, which elicit a reduced or enhanced efficacy. The term "cytokine" is a generic term for proteins released by one cell population which act on another cell as intercellular mediators. Examples of such cytokines are lymphokines, monokines, and traditional polypeptide hormones. Included among the cytokines are growth hormone such as human growth hormone, N-methionyl human growth hormone, and bovine growth hormone; parathyroid hormone; thyroxine; insulin; proinsulin; relaxin; prorelaxin; glycoprotein hormones such as follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH), and luteinizing hormone (LH); hepatic growth factor; fibroblast growth factor; prolactin; placental lactogen; mouse gonadotropin-associated peptide; inhibin; activin; vascular endothelial growth factor (VEGF); integrin; thrombopoietin (TPO); nerve growth factors such as NGFβ; platelet-growth factor; transforming growth factors (TGFs) such as TGFα and TGFβ; erythropoietin (EPO); interferons such as IFNα, JFNG, and IFNγ; colony stimulating factors such as M-CSF, GM-CSF and G-CSF; interleukins such as IL-1, IL-1a, IL-2, lL-3, iL-4, IL-5, IL-6, IL-7, IL-8, IL-9, 1L-10, IL-11,1L-12; and TNFa or TNFS. Preferred cytokines according to the invention are interferons and TNFa. The term "cytotoxic agent" as used herein refers to a substance that inhibits or prevents the function of cells and/or causes destruction of cells. The term is intended to include radioactive isotopes, chemotherapeutic agents, and toxins such as enzymatically active toxins of bacterial, fungal, plant or animal origin, or fragments thereof. The term may include also members of the cytokine family, preferably IFNy as well as antineoplastic agents having also cytotoxic activity. The term "chemotherapeutic agent" or "anti-neopiastic agent" is regarded according to the understanding of this invention as a member of the class of "cytotoxic agents", as specified above, and includes chemical agents that exert anti- neoplastic effects, i.e., prevent the development, maturation, or spread of neoplastic cells, directly on the tumor cell, e.g., by cytostatic or cytotoxic effects, and not indirectly through mechanisms such as biological response modification. Suitable chemotherapeutic agents according to the invention are preferably natural or synthetic chemical compounds, but biological molecules, such as proteins, polypeptides etc. are not expressively excluded. There are large numbers of anti- neoplastic agents available in commercial use, in clinical evaluation and in pre- clinical development, which could be included in the present invention for treatment of tumors / neoplasia by combination therapy with TNFα and the anti-angiogenic agents as cited above, optionally with other agents such as EGF receptor antagonists. It should be pointed out that the chernotherapeutic agents can be administered optionally together with above-said drug combination. Examples of chernotherapeutic or agents include alkylating agents, for example, nitrogen mustards, ethyleneimine compounds, alkyl sulphonates and other compounds with an alkylating action such as nitrosoureas, cisplatin and dacarbazine; antimetabolites, for example, folic acid, purine or pyrimidine antagonists; mitotic inhibitors, for example, vinca alkaloids and derivatives of podophyllotoxin; cytotoxic antibiotics and camptothecin derivatives. Preferred chernotherapeutic agents or chemotherapy include amifostine (ethyoi), cisplatin, dacarbazine (DTIC), dactinomycin, mechlorethamine (nitrogen mustard), streptozocin, cyclophosphamide, carrnustine (BCNU), lomustine (CCNU), doxorubicin (adriamycin), doxorubicin lipo (doxil), gemcitabine (gemzar), daunorubicin, daunorubicin lipo (daunoxome), procarbazine, mitomycin, cytarabine, etoposide, methotrexate, 5-fiuorouracil (5-FU), vinblastine, vincristine, bleomycin, paclitaxel (taxoi), docetaxel (taxotere), aldesleukin, asparaginase, busulfan, carboplatin, cladribine, camptothecin, CPT-11, 10-hydroxy-7-ethyl- camptothecin (SN38), dacarbazine, floxuridine, fludarabine, hydroxyurea, ifosfamide, idarubicin, mesna, interferon alpha, interferon beta, irinotecan, mitoxantrone, topotecan, leuprolide, megestrol, melphalan, mercaptopurine, plicamycin, mitotane, pegaspargase, pentostatin, pipobroman, plicamycin, streptozocin, tamoxifen, teniposide, testolactone, thioguanine, thiotepa,. uracil mustard, vinorelbine, chlorambucil and combinations thereof. Most preferred chernotherapeutic agents according to the invention are cisplatin, gemcitabine, doxorubicin, paclitaxel (taxol) and bleomycin. The terms "cancer" and "tumor" refer to or describe the physiological condition in mammals that is typically characterized by unregulated cell growth. By means of the pharmaceutical compositions according of the present invention tumors can be treated such as tumors of the breast, heart, lung, small intestine, colon, spleen, kidney, bladder, head and neck, ovary, prostate, brain, pancreas, skin, bone, bone marrow, blood, thymus, uterus, testicles, cervix, and liver. More specifically the tumor is selected from the group consisting of adenoma, angio-sarcoma, astrocytoma, epithelial carcinoma, germinoma, glioblastoma, glioma, hamartoma, hemangioendothelioma, hemangiosarcoma, hematoma, hepato- blastoma, leukemia, lymphoma, medulloblastoma, melanoma, neuroblastoma, osteosarcoma, retinoblastoma, rhabdomyosarcoma, sarcoma and teratoma. In detail, the tumor is selected from the group consisting of acral lentiginous melanoma, actinic keratoses, adenocarcinoma, adenoid cycstic carcinoma, adenomas, adenosarcoma, adenosquamous carcinoma, astrocytic tumors, bartholin gland carcinoma, basal cell carcinoma, bronchial gland carcinomas, capillary, carcinoids, carcinoma, carcinosarcoma, cavernous, cholangio-carcinoma, chondosarcoma, choriod plexus papilloma/carcinoma, clear cell carcinoma, cystadenoma, endodermal sinus tumor, endometrial hyperplasia, endometrial stromal sarcoma, endometrioid adenocarcinoma, ependymal, epitheloid, Ewing's sarcoma, fibrolamellar, focal nodular hyperplasia, gastrinoma, germ cell tumors, glioblastoma, glucagonoma, hemangiblastomas, hemangioendothelioma, hemangiomas, hepatic adenoma, hepatic adenomatosis, hepatocellular carcinoma, insulinoma, intaepithelial neoplasia, interepithefial squamous cell neoplasia, invasive squamous cell carcinoma, large cell carcinoma, leiomyosarcoma, lentigo maligna melanomas, malignant melanoma, malignant mesothelial tumors, medulloblastoma, medulloepithelioma, melanoma, meningeal, mesothelial, metastatic carcinoma, mucoepidermoid carcinoma, neuroblastoma, neuroepithelial adenocarcinoma nodular melanoma, oat cell carcinoma, oligodendroglial, osteosarcoma, pancreatic polypeptide, papillary serous adeno-carcinoma, pineal cell, pituitary tumors, plasmacytoma, pseudo-sarcoma, pulmonary blastoma, renal cell carcinoma, retinoblastoma, rhabdomyo-sarcoma, sarcoma, serous carcinoma, small cell carcinoma, soft tissue carcinomas, somatostatin-secreting tumor, squamous carcinoma, squamous cell carcinoma, submesothelial, superficial spreading melanoma, undifferentiated carcinoma, uveal melanoma, verrucous carcinoma, vipoma, well differentiated carcinoma, and Wilm's tumor. The "pharmaceutical compositions" of the invention can comprise agents that reduce or avoid side effects associated with the combination therapy of the present invention ("adjunctive therapy"), including, but not limited to, those agents, for example, that reduce the toxic effect of anticancer drugs, e.g., bone resorption inhibitors, cardioprotective agents. Said adjunctive agents prevent or reduce the incidence of nausea and vomiting associated with chemotherapy, radiotherapy or operation, or reduce the incidence of infection associated with the administration of myelosuppressive anticancer drugs. Adjunctive agents are well known in the art. The immunotherapeutic agents according to the invention can additionally administered with adjuvants like BCG and immune system stimulators. Furthermore, the compositions may include immunotherapeutic agents or chemotherapeutic agents which contain cytotoxic effective radio labeled isotopes, or other cytotoxic agents, such as a cytotoxic peptides (e.g. cytokines) or cytotoxic drugs and the like. The term " pharmaceutical kit" for treating tumors or tumor metastases refers to a package and, as a rule, instructions for using the reagents in methods to treat tumors and tumor metastases. A reagent in a kit of this invention is typically formulated as a therapeutic composition as described herein, and therefore can be in any of a variety of forms suitable for distribution in a kit. Such forms can include a liquid, powder, tablet, suspension and the like formulation for providing the antagonist and/or the fusion protein of the present invention. The reagents may be provided in separate containers suitable for administration separately according to the present methods, or alternatively may be provided combined in a composition in a single container in the package. The package may contain an amount sufficient for one or more dosages of reagents according to the treatment methods described herein. A kit of this invention also contains "instruction for use" of the materials contained in the package. The term "pharmaceutical treatment" refers to therapeutic methods of the present invention for treating tumor cells in tumors and tumor metastases are based on the combined use of angiogenesis inhibiting (anti-angiogenesis) therapy and anti- tumor immunotherapy by using receptor tyrosine kinase blocking agents, preferably ErbB antagonists, above all anti-ErbB1(EGFR, Her1) /anti-ErbB2 (Her2) antibodies. More than one type of angiogenesis inhibiting agent can be used in combination with more than one type of preferably anti-ErbB receptor inhibiting agent. The combined use can occur simultaneously, sequentially, or with the intervention of a period of time between the treatments. Any of the specific therapeutics may be administered more than once during a course of treatment. The method can result in a synergistic potentiation of the tumor cell proliferation inhibition effect of each individual therapeutic, yielding more effective treatment than found by administering an individual component alone. Thus, in one aspect, the method of the invention encompasses administering to a patient, in combination, an amount of an anti- angiogenic agent and an anti-ErbB receptor (Her1/Her2) agent, that may not result in effective angiogenesis inhibition, or anti-tumor cell activity if given in that amount alone. The method of the invention comprises a variety of modalities for practicing the invention in terms of the steps. For example, the agents according to the invention can be administered simultaneously, sequentially, or separately. Furthermore, the receptor tyrosine kinase blocking agent and the anti-angiogenic agent can be separately administered within a time interval of about 3 weeks between administrations, i.e., from substantially immediately after the first active agent is administered to up to about 3 weeks after the first agent is administered. The method can be practiced following a surgical procedure. Alternatively, the surgical procedure can be practiced during the interval between administration of the first active agent and the second active agent. Exemplary of this method is the combination of the present method with surgical tumor removal. Treatment according to the method will typically comprise administration of the therapeutic compositions in one or more cycles of administration. For example, where a simultaneous administration is practiced, a therapeutic composition comprising both agents is administered over a time period of from about 2 days to about 3 weeks in a single cycle. Thereafter, the treatment cycle can be repeated as needed according to the judgment of the practicing physician. Similarly, where a sequential application is contemplated, the administration time for each individual therapeutic will be adjusted to typically cover the same time period. The interval between cycles can vary from about zero to 2 months. The monoclonal antibodies, polypeptides or organic mimetics / chemotherapeutics of this invention can be administered parenteral^ by injection or by gradual infusion over time. Although the tissue to be treated can typically be accessed in the body by systemic administration and therefore most often treated by intravenous administration of therapeutic compositions, other tissues and delivery means are contemplated where there is a likelihood that the tissue targeted contains the target molecule. Thus, monoclonal antibodies, polypeptides or organic agents of this invention can be administered intraocularly, intravenously, intraperitoneally, intramuscularly, subcutaneously, intracavity, transdermally, by orthotopic injection and infusion, and can also be delivered by peristaltic means. The therapeutic compositions containing, for example, an integrin antagonist of this invention are conventionally administered intravenously, as by injection of a unit dose, for example. Therapeutic compositions of the present invention contain a physiologically tolerable carrier together with the relevant agent as described herein, dissolved or dispersed therein as an active ingredient. As used herein, the terms "pharmaceutically acceptable" and grammatical variations thereof, as they refer to compositions, carriers, diluents and reagents, are used interchangeably and represent that the materials are capable of administration to or upon a mammal without the production of undesirable physiological effects such as nausea, dizziness, gastric upset and the like. The preparation of a pharmacological composition that contains active ingredients dissolved or dispersed therein is well understood in the art and need not be limited based on formulation. Typically, such compositions are prepared as injectables either as liquid solutions or suspensions, however, solid forms suitable for solution, or suspensions, in liquid prior to use can also be prepared. The preparation can also be emulsified. The active ingredient can be mixed with excipients which are pharmaceutically acceptable and compatible with the active ingredient and in amounts suitable for use in the therapeutic methods described herein. Suitable excipients are, for example, water, saline, dextrose, glycerol, ethanol or the like and combinations thereof. In addition, if desired, the composition can contain minor amounts of auxiliary substances such as wetting or emulsifying agents., pH buffering agents and the like which enhance the effectiveness of the active ingredient. The therapeutic composition of the present invention can include pharmaceutically acceptable salts of the components therein. Pharmaceutically acceptable salts include the acid addition salts (formed with the free amino groups of the polypeptide) that are formed with inorganic acids such as. for example, hydrochloric or phosphoric acids, or such organic acids as acetic, tartaric, mandelic and the like. Salts formed with the free carboxyl groups can also be derived from inorganic bases such as, for example, sodium, potassium, ammonium, calcium or ferric hydroxides, and such organic bases as isopropylamine, trimethylamine, 2-ethylamino ethanol, histrdine, procaine and the like. Particularly preferred is the HCI salt when used in the preparation of cyclic polypeptide αv antagonists. Physiologically tolerable carriers are well known in the art. Exemplary of liquid carriers are sterile aqueous solutions that contain no materials in addition to the active ingredients and water, or contain a buffer such as sodium phosphate at physiological pH value, physiological saline or both, such as phosphate-buffered saline. Still further, aqueous carriers can contain more than one buffer salt, as well as salts such as sodium and potassium chlorides, dextrose, polyethylene glycol and other solutes. Liquid compositions can also contain liquid phases in addition to and to the exclusion of water. Exemplary of such additional liquid phases are glycerin, vegetable oils such as cottonseed oil, and water- oil emulsions. Typically, a therapeutically effective amount of an immunotherapeutic agent in the form of a, for example, anti-ErbB receptor antibody or antibody fragment or antibody conjugate or an anti-angiogenic receptor antibody, fragment or conjugate is an amount such that when administered in physiologically tolerable composition is sufficient to achieve a plasma concentration of from about 0.01 microgram (μg) per milliliter (ml) to about 100 μg/ml, preferably from about 1 ng/ml to about 5 μg/ml and usually about 5 μg/ml. Stated differently, the dosage can vary from about 0.1 mg/kg to about 300 mg/kg, preferably from about 0.2 mg/kg to about 200 mg/kg, most preferably from about 0.5 mg/kg to about 20 mg/kg, in one or more dose administrations daily for one or several days. Wnere the immunotherapeutic agent is in the form of a fragment of a monoclonal antibody or a conjugate, the amount can readily be adjusted based on the mass of the fragment / conjugate relative to the mass of the whole antibody. A preferred plasma concentration in molarity is from about 2 micromolar (μM) to about 5 millimolar (mM) and preferably, about 100 μM to 1 mM antibody antagonist. A therapeutically effective amount of an agent according of this invention which is a non-immunotherapeutic peptide or a protein polypeptide (e.g. IFN-alpha), or other similarly-sized small molecule, is typically an amount of polypeptide such that when administered in a physiologically tolerable composition is sufficient to achieve a plasma concentration of from about 0.1 microgram (μg) per milliliter (ml) to about 200 μg/ml, preferably from about 1 μg/ml to about 150 ng/ml. Based on a polypeptide having a mass of about 500 grams per mole, the preferred plasma concentration in molarity is from about 2 micromolar (μM) to about 5 millimolar (mM) and preferably about 100 ΜM to 1 mM polypeptide antagonist. The typical dosage of an active agent, which is a preferably a chemical antagonist or a (chemical) chemotherapeutic agent according to the invention (neither an immunotherapeutic agent nor a non-immunotherapeutic peptide/protein) is 10 mg to 1000 mg, preferably about 20 to 200 mg, and more preferably 50 to 100 mg per kilogram body weight per day. The term "therapeutically effective" or "therapeutically effective amount" refers to an amount of a drug effective to treat a disease or disorder in a mammal. In the case of cancer, the therapeutically effective amount of the drug may reduce the number of cancer cells; reduce the tumor size; inhibit (i.e., stow to some extent and preferably stop) cancer cell infiltration into peripheral organs; inhibit (i.e., slow to some extent and preferably stop) tumor metastasis; inhibit, to some extent, tumor growth; and/or relieve to some extent one or more of the symptoms associated with the cancer. To the extent the drug may prevent growth and/or kill existing cancer cells, it may be cytostatic and/or cytotoxic. For cancer therapy, efficacy can, for example, be measured by assessing the time to disease progression (TTP) and/or determining the response rate (RR). Example: The following is a short clinical trial report: A patient, 45 years old, was originally suffering from progressive squamous cell carcinoma of the superior maxilla. EMD 72000: Monoclonal human antibody 425 (h425), Merck KgaA, Germany EMD 121974: Cyclo-(Arg-Gly-Asp-DPhe-NMeVal), Cilengitide®, Merck KgaA, Germany; Chemotherapeutics: various (gemcitabine, cisplatin, etc.) Case history and clinical findings/status at the start of the compassionate use treatment: In July 1997 the patient first presented at the Virchow Klinikum, Germany. A biopsy of the suspected large tumor in the upper maxilla was performed. Histology revealed a squamous cell carcinoma classified as T4 ,N0 MO. On August 5,1997 partial resection of the superior maxilla and resection of regional lymph nodes was done. Histology revealed that no clean margin had been achieved, so an additional resection was performed during the same hospital stay. Due to the unfavourable histologic classification the patient received a post-operative radiation therapy up to 50.4 Gray from September to October 1997. In July 1998 progression of disease was suspected which led to hospitalization. Histology now showed an adenosquamous carcinoma. After consultation of radiotherapists another radiotherapy was recommended which started in August 1998. The patient was treated simultaneously with gemcitabine (100 mg) as a radiosensitizer. The 6 week-therapy led to complete clinical remission. Following the combined radio-chemotherapy the patient received a therapy with 1000 mg gemcitabine (5 circles of 16 administrations). In March 1999 again progression of the carcinoma occurred which led to additional radiation therapy and palliative resection of the tumor. In August 1999 again tumor progression and chemotherapy with cisplatin (75 mg/m2) and docetaxel (75 mg/m2) was started. After three administrations the therapy was stopped due to lack of effect on tumor growth. Diffuse bleedings out of the large tumor mass required frequent transfusions of erythrocyte concentrates. Course of compassionate use treatment with anti-anqioqenic agent / chemotherapeutic agents: Under treatment with EMD 121974 (600 mg/m2) and gemcitabine (Gemzar) (1000mg /m2) in November 1999 a regression of the tumor was diagnosed. Since mid of January 2000 the patient had been able to hear again on his right ear and he had been able to open his mouth 30% more than in December 1999. The surface of the tumor showed signs of granulation and wound healing. Bleeding stopped and there was no need for further transfusions. The patient was treated with EMD 121974 and Gemzar from 17.11.1999 until 30.03.2000. From 06.04.2000 until 28.04.2000 EMD 121974, Gemzar and a chemotherapy with 5-FU,cisplatin and rescuvolin was given to the patient because a progression of the tumor was detected. Chemotherapy-treatment was stopped because of haematotoxicity and Citengitide treatment was continued alone. From April to June 2000 the patient received 600 mg/m2 EMD 121974 twice a week only resulting in stable disease. The patient's condition worsened after several weeks and the patient was treated . with an increased dose of 1200 mg/m2 EMD 121974 twice weekly. Treatment with h425 + Cilenqitide + chemotherapeutics: EMD 72000 was first given in November 2000 in a dosage of 200 mg (infusion over half an hour) after premedication with dexamethasone / dimetindenmaleate ( Fenistil) and ranitidin (Zantic). One week later the patient received additionally gemcitabine (1000mg/m2). The weekly treatment schedule was : Monday: 1200mg/m2 Cilengitide (one hour infusion),Thursday 200 mg EMD 72 000 (half an hour infusion) followed by 1000mg/m2 gemcitabine (one hour infusion), Friday 1200 mg/m2 Cilengitide (one hour infusion). Under this treatment a crater-like disintegration of the tumor mass was observed. The tumor masses were surgically removed at several occasions. The effect of the combined treatment was considered exceptionally impressive by the treating physicians. No therapy related adverse drug reactions in relation to EMD 121974 and EMD 72000 were observed. Up to now the patient's condition remained improved. WE CLAIM: 1. A pharmaceutical composition comprising (i) at least an antibody or an antibody fragment comprising a binding site which binds to an epitope of the ErbB1 (Her1) receptor, said antibody is selected from the group consisting of humanized monoclonal anti-EGFR antibody 425. and chimeric monoclon anti EGFR. antibody 225. and (ii) at least one second agent having an angiogenesis inhibiting specificity, wherein said second agent is an avB3, avB5, or avB6 integrin-inhibiting ROD-containing linear or cyclic peptide, optionally together with a pharmaceutically acceptable carrier, diluent or recipient. 2. A pharmaceutical composition as claimed in claim 1, wherein said RGD-containing peptide is cyclo(Arg'Gly-Asp-DPhe-NMeVal). 3. A pharmaceutical composition as claimed in claim, 1, comprising a chemotherapeutic agent selected from the group consisting of: cisplatin, doxorubicin, gemcitabine, docetaxel, paclitaxel, bleomycin. 4. A pharmaceutical kit comprising (i) a first package comprising at least an antibody or an antibody fragment comprising a binding site which binds to an epitope of the ErbBl(Herl) receptor, said antibody is selected from the group consisting of humanized monoclonal anti-EGFR antibody 425, and chimeric monoclonal anti-EGFR antibody 225., and (ii) an agent having an angiogenesis inhibiting specificity, wherein said agent is an avB3, avB5 or avB6 integrm-inhibiting RGD-containing linear or cyclic peptide. 5. A pharmaceutical kit as claimed in claim 4, wherein said RGD-containing peptide is cyclo(Arg-Gly-Asp-DPhe-NMeVal). 6. A pharmaceutical kit as claimed in claim 4 or 5 comprising a third package comprising a chemotherapeutic agent selected from the group consisting of cisplatin, doxorubicin, gemcitabine, docetaxel, paclitaxel, bleomycin. The invention relates to a combination therapy for the treatment of tumors and tumor metastases comprising administration of receptor tyrosine kinase antagonists/inhibitors, especially ErbB receptor antagonists, more preferably EGF receptor (Her 1)antagonists and anti-angiogenic agents, preferably integrin antagonists, optionally together with agents or therapy forms that have additive or synergistic efficacy when administered together with said combination of antagonists/inhibitors, such as chemotherapeutic agents and or radiation therapy. The therapy can result in a synergistic potential increase of the inhibition effect of each individual therapeutic on tumor cell proliferation, yielding more affective treatment than found by administering an individual component alone.

Full Text

COMOINATION THERAPY USING RECEPTOR TYROSINE KINASE INHIBITORS
AND ANGIOGENESIS INHIBITORS
TECHNICAL FIELD OF THE INVENTION:
The invention relates to a combination therapy for the treatment of tumors and tumor
metastases comprising administration of receptor tyrosine kinase antagonists/
inhibitors, especially ErbB receptor antagonists, more preferably EGF receptor (Her 1)
antagonists and anti-angiogenic agents, preferably integrin antagonists, optionally
together with agents or therapy forms that have additive or synergistic efficacy when
administered together with said combination of antagonists/inhibitors, such as
chemotherapeutic agents and or radiation therapy. The therapy can result in
a synergistic potential increase of the inhibition effect of each individual therapeutic on
tumor cell proliferation, yielding more effective treatment than found by administering
an individual component alone.
BACKGROUND OF THE INVENTION:
The epidermal growth factor receptor (EGF receptor or EGFR), also known as c-
erbB1/Her 1, and the product of the neu oncogene (also known as c-erbB2/Her 2) are
the members of the EFG receptor super family, which belongs to the large family of
receptor tyrosine kinases. They interact at the cell surface with specific growth factors
or natural ligands, such as EGF or TGF alpha, thus, activating the receptor tyrosine
kinase. A cascade of downstream signaling proteins are activated in general leading
to altered gene expression and increased growth rates.
C-erbB2 (Har 2) is a transmembrane tyrosine kinase having a molecular weight of,
about 185(000, with considerable homology to the EGF receptor (Her 1), although a
specific ligand for Her 2 has not yet been clearly identified so far.
The .EGF receptor is a transmembrane glycoprotein which has a molecular weight of
170.000, And is found on many epithelial cell types. It is activated by at least three
ligands, EGF, TGF-α (transforming growth factor alpha) and amphiregulin. Both
epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-a) have
been demonstrated to bind to EGF receptor and to lead to cellular proliferation and
tumor growth. These growth factors do not bind to Her 2 (Ulrich and Schlesinger,
1990, Cell 61, 203). In contrast to several families of growth factors, which induce

receptor dimerization by virtue of their dimeric nature (e.g. PDGF) monomeric growth
factors, such as EGF, contain two binding sites for their receptors and, therefore, can
cross-link two neighboring EGF receptors (Lemmon et al., 1997, EMBO J. 16,281).
Receptor dimerization is essential for stimulating of the intrinsic catalytic activity and
for the autophosphorylation of growth factor receptors. It should be remarked that
receptor protein tyrosine kinases (PTKs) are able to undergo both homo- and
heterodimerization.
Clinical studies indicate that both EGF receptor and c-erbB2 are overexpressed in
certain types of tumors, especially, breast, ovary, bladder, colon, kidney, head and
neck cancers and squamous carcinomas of the lung. (Mendelsohn, 1989, Cancer
Cells 7,359; Mendelsohn, 1990, Cancer Biology 1, 339). Therefore, these
observations have stimulated preclinical investigations targeting on inhibiting the
function of human EGF receptors or c-erbB2 as novel therapeutic approaches to
treat cancer (see e.g. Baselga et al., 1996, J. Clin. Oncol. 14, 737; Fan and
Mendelsohn, 1998, Curr. Opin. Oncol. 10, 67). It has been reported that, for example,
anti-EGF receptor antibodies as well as anti-Her 2 antibodies show fruitful results in
human cancer therapy. Thus, humanized monoclonal antibody 4D5 (hMAb 4D5,
HERCEPTIN®) is already a commercialized product.
It has been demonstrated that anti-EGF receptor antibodies while blocking EGF and
TGF-a binding to the receptor appear to inhibit tumor cell proliferation. In view of
these findings, a number of murine and rat monoclonal antibodies against EGF
receptor have been developed and tested for their ability inhibit the growth of tumor
cells in vitro and in vivo (Modjtahedi and Dean, 1994, J. Oncology 4, 277). Humanized
monoclonal antibody 425 (hMAb 425) (US 5,558,864; EP 0531 472) and chimeric
monoclonal antibody 225 (cMAb 225) (Naramura et al., 1993, Cancer Immunol.
Immunother. 37, 343-349.WO 96/40210), both directed to the EGF receptor, have
shown their efficacy in clinical trials. The C225 antibody was demonstrated to inhibit
EGF-mediated tumor cell growth in vitro and inhibit human tumor formation in vivo in
nude mice. The antibody, moreover, appeared to act, above all, in synergy
with certain chemotherapeutic agents (i.e., doxorubicin, adriamycin, taxol, and
cisplatin) to eradicate human tumors in vivo in xenograft mouse models. Ye et al.

(1999, Oncogene 18, 731) have reported that human ovarian cancer cells can be
treated successfully with a combination of both cMAb 225 and hMAb 4D5.
Angiogenesis, also referred to as neovascularization, is a process of tissue
vascularization that involves the growth of new blood vessels into a tissue. The
process is mediated by the infiltration of endothelial cells and smooth muscle ceils.
The process is believed to proceed in any one of three ways: (1) the vessels can
sprout from pre-existing vessels; (2) de novo development of vessels can arise from
precursor cells (vasculogenesis); or (3) existing small vessels can enlarge in diameter
(Blood et al., 1990, Bioch. Biophys. Acta 1032, 89. Vascular endothelial cells are
known to contain at least five RGD-dependent integrins, including the vitronectin
receptor (αvβ3 or αvβ3), the collagen Types I and IV receptor, the laminin receptor,
the fibronectin/laminin/collagen receptor and the fibronectin receptor (Davis et al.,
1993, J. Cell. Biochem. 51, 206). The smooth muscle cell is known to contain at least
six RGD-dependent integrins, including αvβ3 αvβ5.
Inhibition of cell adhesion in vitro using monoclonal antibodies immunospecific
for various integrin a or B subunits have implicated the vitronectin receptor αvβ3 in cell
adhesion of a variety of cell types including microvascular endothelial cells (Davis et
al., 1993, J. Cell. Biol. 51, 206).
Integrins are a class of cellular receptors known to bind extracellular matrix proteins,
and mediate cell-extracellular matrix and cell-cell interactions, referred generally to as
cell adhesion events. The integrin receptors constitute a family of proteins with shared
structural characteristics of non-covalent heterodimeric glycoprotein complexes
formed of a and 3 subunits. The vitronectin receptor, named for its original
characteristic of preferential binding to vitronectin, is now known to refer to three
different integrins, designated αvβ1, αvβ3 and avB5. αvβ1 binds fibronectin and
vitronectin. αvβ3 binds a large variety of ligands, including fibrin, fibrinogen, laminin,
thrombospondin, vitronectin and von Willebrand's factor. αvβ5 binds vitronectin. It is
clear that there are different integrins with different biological functions as well as
different integrins and subunits having shared biological specificity and function. One
important recognition site in a ligand for many integrins is the arginine-glycine-
aspartic acid (RGD) tripeptide sequence. RGD is found in all of the ligands identified

above for the vitronectin receptor integrins. This RGD recognition site can be
mimicked by linear and cyclic (poly)peptides that contain the RGD sequence. Such
RGD peptides are known to be inhibitors or antagonists, respectively, of integrin
function. It is important to note, however, that depending upon the sequence
and structure of the RGD peptide, the specificity of the inhibition can be altered to
target specific integrins. Various RGD polypeptides of varying integrin specificity
have been described, for example, by Cheresh, et al., 1989, Cell 58, 945, Aumailley
et al., 1991, FEBS Letts. 291,50, and in numerous patent applications and patens
(e.g. US patents 4,517,686, 4,578,079, 4,589,881,4,614,517, 4,661,111, 4,792,525;
EP 0770 622).
The generation of new blood vessels, or angiogenesis, plays a key role in the growth
of malignant disease and has generated much interest in developing agents that
inhibit angiogenesis (see, for example, Holmgren et al., 1995, Nature Medicine 1,
149; Folkman, 1995, Nature Medicine 1, 27; O'Reilly et. al., 1994, Cell 79, 315). The
use of αvβ3 integrin antagonists to inhibit angiogenesis is known in methods to inhibit
solid tumor growth by reduction of the blood supply to the solid tumor (see, for
example, US 5,753,230 and US 5,766,591, which describe the use of αvβ3
antagonists such as synthetic polypeptides, monoclonal antibodies and mimetics of
αvβ3 that bind to the αvβ3 receptor and inhibit angiogenesis). Methods and
compositions for inhibiting αvβ5 mediated angiogenesis of tissues using antagonists of
the vitronectin receptor αvβ3 are disclosed in WO 97/45447. Angiogenesis is
characterized by invasion, migration and proliferation of endothelial cells, processes
that depend on cell interactions with extracellular matrix components. In this context,
the integrin cell-matrix receptors mediate cell spreading and migration. The
endothelial adhesion receptors of integrin αvβ3 were shown to be key players by
providing a vasculature-specific target for anti-angiogenic treatment strategies
(Brooks et al., 1994, Science 264, 569; Friedlander et. al., 1995, Science 270). The
requirement for vascular integrin αvβ3 in angiogenesis was demonstrated by several
in vivo models where the generation of new blood vessels by transplanted human
tumors was entirely inhibited either by systemic administration of peptide antagonists
of integrin αvβ3 and αvβ3, as indicated above, or, alternatively, by anti- αvβ3 antibody

LM609 (Brooks et al., 1994, Cell 79, 1157; ATCC HB 9537). This antibody blocks the
αvβ3 integrin receptor the activation of which by its natural ligands promotes apoptosis
of the proliferative angiogenic vascular cells and thereby disrupts the maturation of
newly forming blood vessels, an event essential for the proliferation of tumors.
Nevertheless, it was recently reported, that melanoma cells could form web-like
patterns of blood vessels even in the absence of endothelial cells (1999, Science 285,
14), implying that tumors might be able to circumvent some anti-angiogenic drugs
which are only effective in the presence of endothelial tissue.
Numerous molecules stimulate endothelial proliferation, migration and assembly,
including VEGF, Ang1 and bFGF, and are vital survival factors. VEGF (Vascular
Endothelial Growth Factor) has been identified as a selective angiogenic growth
factor that can stimulate endothelial cell mitogenesis. VEGF, in particular, is thought
to be a major mediator of angiogenesis in a primary tumor and in ischemic ocular
diseases. VEGF is a homodimer (MW : 46.000) that is an endothelial cell-
specific angiogenic (Ferrara et al., 1992, Endocrin. Rev., 13,18) and
vasopermeability factor (Senger et al., 1986, Cancer Res., 465629) that binds to high-
affinity membrane-bound receptors with tyrosine kinase activity (Jakeman et al., 1992,
J. Clin. Invest., 89, 244). Human tumor biopsies exhibit enhanced expression of
VEGF mRNAs by malignant cells and VEGF receptor mRNAs in adjacent endothelial
cells. VEGF expression appears to be greatest in regions of tumors adjacent to
vascular areas of necrosis, (for review see Thomas et al., 1996, J* Biol. Chem.
271(2), 603; Folkman, 1995, Nature Medicine 1, 27). WO 97/45447 has implicated the
αvβ5 integrin in neovascularization, particularly, that induced by VEGF, EGF and TGF-
α, and discloses that αvβ5 antagonist can inhibit VEGF promoted angiogenesis.
Effective anti-tumor therapies may also utilize targeting VEGF receptor for inhibition of
angiogenesis using monoclonal antibodies. (Witte et a!., 1998, Cancer Metastasis
Rev. 17(2), 155). MAb DC-101 is known to inhibit angiogenesis of tumor cells.
As summarized above it is evident that EGF, VEGF and integrins αvβ3 and αvβ5 and
their receptors are basically involved in tumor proliferation and tumor angiogenesis,
and that effective inhibitors, especially monoclonal antibodies, directed to EGF

receptor and/or VEGF receptor and/or integrin receptors or any other protein tyrosine
kinase receptors are principally suitable candidates for tumor therapy. Monoclonal
antibodies which can specifically recognize their antigen epitopes on the relevant
receptors, are of special interest
However, the use of such antibodies, which were successful in vitro and in animal
models, have not shown satisfying efficacy in patients as mono-drug therapy. Similar
results were obtained when other anti-angiogenic or EGF receptor antagonists than
antibodies were used in clinical trials. It seems, that tumors, if some specific sites are
blocked, may use other cell surface molecules to compensate for said original
blocking. Thus, tumors do not really shrink during various anti-angiogenic or anti-
proliferative therapies. For these reasons, combination therapies were proposed to
circumvent this problem using monoclonal antibodies together with cytotoxic or
chemotherapeutic agents or in combination with radiotherapy. Indeed, clinical trials
have shown that these combination therapies are more efficient than the
corresponding mono-administrations. Thus, for example, antibody-cytokine fusion
protein therapies have been described which promote immune response-mediated
inhibition of established tumors such as carcinoma metastases. For example, the
cytokine interleukin 2 (IL-2) has been fused to specific monoclonal antibodies KS1/4
and ch14.18 directed to the tumor associated antigens epithelial cell adhesion
molecule (Ep-CAM, KSA, KS1/4 antigen) or the disialoganglioside GD, respectively,
to form the fusion proteins ch14.18-IL-2 and KS1/4-IL-2, respectively (US 5,650,150).
Another clinical approach is based on the administration of monclonal antibody c225
in combination with Herceptin® (Ye et al, 1999, I.e.). Furthermore, the combination of
anti-EGF receptor antibodies together with anti-neoplastic agents, such as cisplatin or
doxorubicin, was disclosed in EP 0667 165 (A1) and US 6,217,866); a similar
combination, especially a combination of Herceptin® with cisplatin and other cytotoxic
factors, was described in Genentech's US 5,770,195. Synergy effects between an
anti-angiogenic integrin Ov antagonist and above-mentioned antibody-cytokine fusion
proteins were observed in tumor metastases (Lode et aL 1999, Proc. Natl. Acad. Sci.
96,1591, WO 00/47228). Methods of using integrin antagonists together with anti-
neoplastic agents were recently claimed in WO 00/38665. Recently, it was found that

a combination of gemcitabine with specific monoclonal antibody DC-101, which
inhibits angiogenesis, increased the anti-tumor effect in pancreatic cancer of mice
compared with gemcitabine alone. DE 198 42415 discloses the combination of a
specific cyclic RGD peptide as integrin inhibitor with specific anti-angiogenesis
agents. Other approaches suggest the administration of EGF receptor blocking
agents, antibodies included, or integrin antagonists combined with radiation or
radiotherapy, respectively (e.g. WO 99/60023, WO 00/0038715).
Nevertheless, although various combinations therapies are under investigation and in
clinical trials, the outcome of these therapies are not fruitful enough. Therefore, it is a
need to develop further combinations which can show increased efficacy and reduced
side-effects.
SUMMARY OF THE INVENTION:
The present inventions describes for the first time a novel pharmaceutical treatment
which is based on the new concept in tumor therapy to administer to an individual in a
therapeutically effective amount an agent that blocks or inhibits a receptor tyrosine
kinase, preferably an ErbB receptor and more preferably an EGF receptor together
with an anti-angiogenic agent. Optionally the composition according to this invention
may comprise further therapeutically active compounds, preferably selected from the
group consisting of cytotoxic agents, chemotherapeutic agents and other
pharmacologically active compounds which may enhance the efficacy of said agents
or reduce the side effects of said agents.
Thus, the invention relates to pharmaceutical compositions comprising as preferred
ErbB receptor antagonists an anti-EGFR (ErbB1 / Her 1) antibody and as anti-
angiogenic agent an inhibitor or antagonist of any of the αvβ3, αvβ5 or αvβ6 integrin
receptors, preferably an RGD containing linear or cyclic peptide. Especially, the
inventions relates, as a preferred embodiment, to a specific combination therapy
comprising anti-EGFR or anti-Her2 antibodies, such as humanized monoclonal
antibody 425 (h425, EMD 72000), chimeric monoclonal antibody 225 (c225) or
Herceptin® together with preferably RGD-containing integrin inhibitors, most

preferably with the cyclic peptide cyclo-(Arg-Gly-Asp-DPhe-NMe-Val), optionally
together with a chemotherapeutic compound.
According to this invention said therapeutically active agents may also be provided by
means of a pharmaceutical kit comprising a package comprising one or more
receptor tyrosine kinase antagonists, one or more anti-angiogenic agents, and
optionally, one or more cytotoxic / chemotherapeutic agents in single packages or in
separate containers. The therapy with this combinations may include optionally
treatment with radiation.
However, the invention relates, furthermore, to a combination therapy comprising the
administration of only one (fusion) molecule, having anti-receptor tyrosine kinase,
preferably anti-ErbB receptor activity and anti-angiogenic activity, optionally together
with one or more cytotoxic / chemotherapeutic agents. An example is an anti-EGFR
antibody, such as h425 or c225 as described above and below, which is fused at the
C-terminal of its Fc portion to an anti-hormonal agent by known recombinant or
chemical methods. A further example is a bispecific antibody, whereinone specificity
is directed to an nuclear hormone receptor and the other one is directed to the EGF
receptor.
Principally, the administration can be accompanied by radiation therapy, wherein
radiation treatment can be done substantially concurrently or before or after the drug
administration. The administration of the different agents of the combination therapy
according to the invention can also be achieved substantially concurrently or
sequentially. Tumors, bearing receptors on their cell surfaces involved in the
development of the blood vessels of the tumor, may be successfully treated by the
combination therapy of this invention.
It is known that tumors elicit alternative routes for their development and growth. If
one route is blocked they often have the capability to switch to another route by
expressing and using other receptors and signaling pathways. Therefore, the
pharmaceutical combinations of the present invention may block several of such

possible development strategies of the tumor and provide consequently various
benefits. The combinations according to the present invention are useful in treating
and preventing tumors, tumor-like and neoplasia disorders and tumor metastases,
which develop and grow by activation of their relevant hormone receptors which are
present on the surface of the tumor cells. Preferably, the different combined agents of
the present invention are administered in combination at a low dose, that is, at a dose
lower than has been conventionally used in clinical situations. A benefit of lowering
the dose of the compounds, compositions, agents and therapies of the present
invention administered to an individual includes a decrease in the incidence of
adverse effects associated with higher dosages. For example, by the lowering the
dosage of an agent described above and below, a reduction in the frequency and the
severity of nausea and vomiting will result when compared to that observed at higher
dosages. By lowering the incidence of adverse effects, an improvement in the quality
of life of a cancer patient is contemplated. Further benefits of lowering the incidence
of adverse effects include an improvement in patient compliance, a reduction in the
number of hospitalizations needed for the treatment of adverse effects, and a
reduction in the administration of analgesic agents needed to treat pain associated
with the adverse effects. Alternatively, the methods and combination of the present
invention can also maximize the therapeutic effect at higher doses.
Tumors, bearing (over-expressed) ErbB receptors, preferably ErbB1 (Her1, EGFR) of
ErbB2 (Her 2) receptors on their cell surfaces, may be successfully treated by the
combinations according to the inventions. The combinations within the
pharmaceutical treatment according to the inventions show an astonishing synergetic
effect. In administering the combination of drugs real tumor shrinking and
disintegration could be observed during clinical studies while no significant adverse
drug reactions were detectable. Above all, the three-drug combinations (receptor
tyrosine kinase, preferably ErbB receptor blocking agent plus anti-angiogenic agent
plus chemotherapeutic agent) show superior efficacy. However, whether a
chemotherapeutic drug is synergistically effective or not depends on the drug itself,
the receptor tyrosine kinase, preferably ErbB receptor antagonist and the tumor cell
that is treated with said agents, and must be usually checked case by case.

In detail the invention refers to:
• a pharmaceutical composition comprising an agent or agents having
(i) at least one receptor tyrosine kinase blocking / inhibiting specificity and
(ii) at least one angiogenesis blocking / inhibiting specificity,
wherein said agent or agents is / are not a cytokine immunoconjugate,
optionally together with a pharmaceutically acceptable carrier, diluent or
recipient;
• as a first alternative, a pharmaceutical comprising
(i) at least one agent having a receptor tyrosine kinase blocking specificity, and
(ii) at least one agent having an angiogenesis inhibiting specificity;
• as a second alternative, a pharmaceutical composition, comprising an agent
having a receptor tyrosine kinase blocking specificity as well as an
angiogenesis inhibiting specificity.
• corresponding compositions further comprising at least one cytotoxic,
preferably chemotherapeutic agent;
• in more detail, a pharmaceutical composition, wherein said agent (i) has a
ErbB receptor blocking / inhibiting specificity;
• a corresponding pharmaceutical composition, wherein the ErbB receptor
specificity of said agent is related to the EGF receptor (ErbB1/Her1) or the
ErbB2/Her2 receptor;
• in more detail, a pharmaceutical composition, wherein said agent is an
antibody or a functionally intact derivative thereof, comprising a binding site
which binds to an epitope of the ErbB1 (Her1) or Erb2 (Her2) receptor;
• as preferred embodiment, a pharmaceutical composition, wherein said
antibody or functionally intact derivative thereof is selected from the group:
humanized monoclonal antibody 425 (h425)
chimeric monoclonal antibody 225 (c225)
humanized monoclonal antibody Her 2, the corresponding humanized,
chimeric or de-immunized functionally intact dervatives included;
• a corresponding pharmaceutical composition, wherein said angiogenesis
inhibiting agent is an αvβ3, αvβ5 or anαvβ6 integrin inhibitor;

• a corresponding pharmaceutical composition, wherein said integrin inhibitor is
an RGD-containing linear or cyclic peptide, preferably cyclo(Arg-Gly-Asp-
DPhe-NMeVal);
• as a specific embodiment, a pharmaceutical composition, wherein said
antibody or functionally intact derivative thereof is humanized monoclonal
antibody 425 (h425) or chimeric monoclonal antibody 225 (c225), de-
immunized forms included, and said integrin inhibitor is cyclo(Arg-Gly-Asp-
DPhe-NMeVal), optionally comprising, optionally in separate containers or
packages, a chemotherapeutic agent which is selected from any of the
compounds of the group: cisplatin, doxorubicin, gemcitabine, docetaxel,
paclitaxel, bleomycin;
• a corresponding pharmaceutical composition, wherein said integrin inhibitor is
an antibody or a functionally intact derivative thereof, comprising a binding site
which binds to an epitope of an integrin receptor, preferably selected from the
group of antibodies: LM609, P1F6,17E6,14D9.F8, humanized, chimeric and
de-immunized versions thereof included;
• a pharmaceutical composition, wherein one of said agents is a bispecific
antibody or a heteroantibody molecule comprising a first binding site that binds
to an epitope of a receptor tyrosine kinase, preferably ErbB receptor, and a
second binding site that binds to an epitope of an angiogenesis receptor,
preferably an integrin receptor;
• a specific corresponding pharmaceutical composition, wherein said monoclonal
antibodies are selected from h425, c225 or Her 2, and from the monoclonal
antibodies LM609, P1F6,17E6 and 14D9.F8;
• a pharmaceutical composition, wherein one of said agents is an
immunoconjugate consisting of an antibody or antibody fragment, bearing one
of said blocking specificities, and a non-immunological molecule, fused to the
antibody or antibody fragment bearing the other specificity;
• a corresponding pharmaceutical composition, wherein the antibody portion or
fragment thereof comprises a binding site that binds to an epitope of an ErbB
receptor, preferably an EGF receptor (Her 1), and the fused non-immunological

molecule comprises a binding site that binds to an epitope of an integrin
receptor;
• a specific pharmaceutical composition thereof, wherein said antibody portion
which binds to an epitope of an ErbB receptor is selected from monoclonal
antibodies h425, c225 or Her 2, and said non-imunological portion which binds
to an epitope of an integrin receptor is cyclo(Arg-Gly-Asp-DPhe-NMeVal);
• a pharmaceutical kit comprising
(i) a package comprising at least one receptor tyrosine kinase inhibiting,
preferably an ErbB receptor blocking agent, and
(ii) a package comprising at least one angiogenesis inhibiting agent, preferably
an αvβ3, αvβ5 or an αvβ6 integrin receptor inhibiting agent, more preferably an
RGD-containing linear or cyclic peptide, especially cyclo(Arg-Gly-Asp-DPhe-
NMeVal);
optionally further comprising a package comprising a cytotoxic agent;
• a corresponding pharmaceutical kit, wherein said ErbB receptor blocking agent
is an antibody or a functionally intact derivative thereof, having a binding site
that binds to an epitope of said receptor; said antibody is preferably selected
from the group of antibodies: humanized monoclonal antibody 425 (h425),
chimeric monoclonal antibody 225 (c225) or humanized monoclonal antibody
Her 2;
• a pharmaceutical kit, wherein said angiogenesis inhibiting agent is an antibody
or an active derivative thereof, preferably selected from the group of
antibodies: LM609, P1H6,17E6 and 14D9.F8;
• as specific embodiment of the invention, a specific pharmaceutical kit,
comprising
(i) a package comprising humanized monoclonal antibody 425 (h425), chimeric
monoclonal antibody 225 (c225), or a functionally intact derivative thereof, and
(ii) a package comprising cyclo(Arg-Gly-Asp-DPhe-NMeVal), optionally
comprising a chemotherapeutic agent which is selected from any of the
compounds of the group: cisplatin, doxorubicin, gemcitabine, docetaxel,
paclitaxel, bleomycin;

• the use of a pharmaceutical composition or a pharmaceutical kit as defined
above, below and in the claims, for the manufacture of a medicament to treat
tumors and tumor metastases;
• a pharmaceutical treatment or method for treating tumors or tumor metastases
in a patient comprising administering to said patient a therapeutically effective
amount of an agent or agents having
(i) at least one receptor tyrosine kinase blocking specificity and
(ii) at least one angiogenesis inhibiting specificity,
wherein said agent or agents is / are not a cytokine immunoconjugate,
optionally together with a cytotoxic, preferably chemotherapeutic agent,
and wherein, preferably, said agent (i) is an antibody or a functionally intact
derivative thereof, comprising a binding site which binds to an epitope of the
ErbB receptor, preferably, ErbB1(Her1) or Erb2(Her2) receptor, and said agent
(ii) is a αvβ3, αvβ5 or an αvβ6 integrin inhibitor or a VEGF receptor blocking
agent; and finally
• a corresponding method, wherein said antibody directed to the ErbB receptor
is selected from the group: humanized monoclonal antibody 425 (h425),
chimeric monoclonal antibody 225 (c225) or humanized monoclonal antibody
Her 2, and anti-angiogenic agent is cycio(Arg-Gly-Asp-DPhe-NMeVal),
optionally together with a cytotoxic drug selected from the group: cisplatin,
doxorubicin, gemcitabine, docetaxel, paclitaxel, bleomycin.
The pharmaceutical treatment using the pharmaceutical compositions and kits
according to the invention may be accompanied, concurrently or sequentially, by a
radiation therapy.
Principally, four different combinations of pharmaceutical compositions can be
distinguished according to the invention:
(i) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity combined with an agent comprising at least one
anti-angiogenic activity (two-drug combination);

(ii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity combined with an agent comprising at least one
anti-angiogenic activity and combined with at least one chemotherapeutic agent
(three-drug combination);
(iii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity as well as at least one anti-angiogenic activity
combined in one molecule (one-drug combination having two-drug activity);
(iv) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity as well as at least one anti-angiogenic activity
combined in one molecule, combined with at least one chemotherapeutic agent (two-
drug combination having three-drug activity);
The agents can be administered concurrently or sequentially in any of said cases.
According to the above-said, the methods of the invention comprise, in principal, the
following combinations of administration:
(i) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity combined with an agent comprising at least one
anti-angiogenic activity (two-drug administration);
(ii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity combined with an agent comprising at least one
anti-angiogenic activity (two- drug administration) and radiotherapy;
(iii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity combined with an agent comprising at least one
anti-angiogenic activity combined with at least one chemotherapeutic agent (three-
drug administration);
(iv) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity combined with an agent comprising at least one
anti-angiogenic activity combined with at least one chemotherapeutic agent (three-
drug administration) and radiotherapy;
(v) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity as well as at least one anti-angiogenic activity
combined in one molecule (one-drug administration having "two-drug activity");

(vi) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity as well as at least one anti-angiogenic activity
combined in one molecule (one-drug administration having "two-drug activity") and
radiotherapy;
(vii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity as well as at least one anti-angiogenic activity
combined in one molecule combined with at least one chemotherapeutic agent (two-
drug administration having "three-drug activity");
(viii) an agent comprising at least one receptor tyrosine kinase, preferably ErbB
receptor blocking activity / specificity as well as at least one anti-angiogenic activity
combined in one molecule combined with at least one chemotherapeutic agent (two-
drug administration having "three-drug activity") and radiotherapy.
The pharmaceutical combinations and methods of the present invention provide
various benefits. The combinations according to the present invention are useful in
treating and preventing tumors, tumor-like and neoplasia disorders. Preferably, the
different combined agents of the present invention are administered in combination at
a low dose, that is, at a dose lower than has been conventionally used in clinical
situations. A benefit of lowering the dose of the compounds, compositions, agents
and therapies of the present invention administered to a mammal includes a
decrease in the incidence of adverse effects associated with higher dosages. For
example, by the lowering the dosage of a chemotherapeutic agent such as
methotrexate, doxorubicin, gemcitabine, docetaxel, paclitaxel, bleomycin or cisplatin,
a reduction in the frequency and the severity of nausea and vomiting will result when
compared to that observed at higher dosages. Similar benefits are contemplated for
the compounds, compositions, agents and therapies in combination with the integrin
antagonists of the present invention. By lowering the incidence of adverse effects,
an improvement in the quality of life of a cancer patient is contemplated. Further
benefits of lowering the incidence of adverse effects include an improvement in
patient compliance, a reduction in the number of hospitalizations needed for the
treatment of adverse effects, and a reduction in the administration of analgesic agents
needed to treat pain associated with the adverse effects.

Alternatively, the methods and combination of the present invention can also
maximize the therapeutic effect at higher doses.
DETAILED DESCRIPTION OF THE INVENTION
If not otherwise pointed out the terms and phrases used in this invention have the
meanings and definitions as given below. Moreover, these definitions and meanings
describe the invention in more detail, preferred embodiments included.
A "receptor" or "receptor molecule" is a soluble or membrane bound / associated
protein or glycoprotein comprising one or more domains to which a ligand binds to
form a receptor-ligand complex. By binding the ligand, which may be an agonist or an
antagonist the receptor is activated or inactivated and may initiate or block pathway
signaling.
By" ligand" or "receptor ligand" is meant a natural or synthetic compound which
binds a receptor molecule to form a receptor-ligand complex. The term ligand
includes agonists, antagonists, and compounds with partial agonist/antagonist action.
An "agonist" or "receptor agonist" is a natural or synthetic compound which binds
the receptor to form a receptor-agonist complex by activating said receptor and
receptor-agonist complex, respectively, initiating a pathway signaling and further
biological processes.
By "antagonist" or "receptor antagonist" is meant a natural or synthetic compound
that has a biological effect opposite to that of an agonist. An antagonist binds the
receptor and blocks the action of a receptor agonist by competing with the agonist
for receptor. An antagonist is defined by its ability to block the actions of an agonist. A
receptor antagonist may be also an antibody or an immunotherapeutically effective
fragment thereof. Preferred antagonists according to the present invention are cited
and discussed below.

An "ErbB receptor" is a receptor protein tyrosine kinase which belongs to the ErbB
receptor family and includes EGFR(ErbBl), ErbB2, ErbB3 and ErbB4 receptors and
other members of this family to be identified in the future. The ErbB receptor will
generally comprise an extracellular domain, which may bind an ErbB ligand; a
lipophilic transmembrane domain; a conserved intracellular tyrosine kinase domain;
and a carboxyl-terminal signaling domain harboring several tyrosine residues which
can be phosphorylated. The ErbB receptor may be a "native sequence" ErbB receptor
or an "amino acid sequence variant" thereof. Preferably the ErbB receptor is native
sequence human ErbB receptor. ErbB1 refers to the gene encoding the EGFR protein
product. Mostly preferred is the EGF receptor (Her 1). The expressions "ErbB1" and
"Her 1" are used interchangeably herein and refer to human Her 1 protein. The
expressions "ErbB2" and "Her 2" are used interchangeably herein and refer to human
Her 2 protein. ErbB1 receptors (EGFR) are preferred according to this invention
"ErbB ligand" is a polypeptide which binds to and/or activates an ErbB receptor.
ErbB ligands which bind EGFR include EGF, TGF-a, amphiregulin, betacellulin, HB-
EGF and epiregulin.
The term "tyrosine kinase antagonist/inhibitor" refers to natural or synthetic agents
that are enabled to inhibit or block tyrosine kinases, receptor tyrosine kinases
included, which are of specific interest of this invention. Thus, the term includes "ErbB
receptor antagonists/inhibitors', which are defined below in more detail. With
exception of these antagonists, preferably anti-ErbB receptor antibodies additionally
suitable tyrosine kinase antagonists of the invention are chemical compounds which
have shown efficacy in mono- drug therapy for, e.g., breast and prostate cancer.
Suitable indolocarbazole-type tyrosine kinase inhibitors can be obtained using
information found in documents such as US patents 5,516,771; 5,654,427;
5,461,146; 5,650,407. US patents 5,475,110; 5,591,855; 5,594,-009 and WO
96/11933 disclose pyrrolocarbazole-type tyrosine kinase inhibitors and prostate
cancer. Preferably, the dosage of the chemical tyrosine kinase inhibitors as defined
above is from 1 pg/kg to 1 g/kg of body weight per day. More preferably, the dosage
of tyrosine kinase inhibitors is from 0.01 mg/kg to 100 mg/kg of body weight per day.

The term 'ErbB receptor antagonist / inhibitor" refers to a natural or synthetic
molecule which binds and blocks or inhibits the ErbB receptor, and is therefore a
member of the "(receptor) tyrosine kinase antagonist/inhibitor" family. Thus, by
blocking the receptor the antagonist prevents binding of the ErbB ligand (agonist) and
activation of the agonist/ligand receptor complex. ErbB antagonists may be directed
to Her 1 (or EGFR / Her 1) or Her 2. Preferred antagonists of the invention are
directed to the EGF receptor (EGFR, Her 1). The ErbB receptor antagonist may be an
antibody or an immunotherapeutically effective fragment thereof or non-
immunobiological molecules, such as a peptide, polypeptide protein. Chemical
molecules are also included, however, anti-EGFR antibodies and anti-Her 2
antibodies are the preferred antagonists according to the invention.
Preferred antibodies of the invention are anti-Herl and anti-Her2 antibodies, more
preferably anti-Herl antibodies. Preferred anti-Herl antibodies are MAb 425,
preferably humanized MAb 425 (hMAb 425, US 5,558,864; EP 0531 472) and
chimeric MAb 225 (cMAb 225, US 4,943,533 and EP 0359 282). Most preferred is
monoclonal antibody h425, which has shown in mono-drug therapy high efficacy
combined with reduced adverse and side effects,.Most preferred anti-Her2 antibody is
HERCEPTIN® commercialized by Genentech/Roche.
Efficacious EGF receptor antagonists according to the invention may be also other
natural or synthetic chemical compounds. Some examples of preferred molecules of
this category include organic compounds, organometallic compounds, salts of organic
and organometallic compounds.
Efficacious ErbB receptor antagonists according to the invention may be also small
molecules. Small molecules of the invention are not biological molecules as defined
above having a molecular weight of approximately not greater than 400. Preferably,
they have no protein or peptide structure, and are most preferably synthetically
produced chemical compounds. Some examples of preferred small molecules include
organic compounds, organometallic compounds, salts of organic and organometallic
compounds.
Numerous small molecules have been described as being useful to inhibit EGF
receptor and / or Her 2 receptor. Examples are: styryl substituted heteroaryl
compounds (US 5,656,655); bis mono and/or bicyclic aryl heteroaryl, carbocyctic, and

heterocarbocyclic compounds (US 5,646,153); tricyclic pyrimidine compounds (US
5,679,683); quinazoline derivatives having receptor tyrosine kinase inhibitory activity
(US 5,616,582); heteroarylethenediyl or heteroarylethenediylaryl compounds (US
5,196,446); a compound designated as 6-(2,6-dichlorophenyl)-2-(4-(2-diethyl-
aminoethoxy) phenylamino)-8-methyl-8H-pyrido(2,3)-5-pyrirnidin-7-one (Panek, et al.,
1997, J. Pharmacol. Exp. Therap. 283,1433) inhibiting EGFR, PDGFR, and FGFR
families of receptors.
An "anti-angiogenic agent' refers to a natural or synthetic compound which blocks,
or interferes with to some degree, the development of blood vessels. The anti-
angiogenic molecule may, for instance, be a biological molecule that binds to and
blocks an angiogenic growth factor or growth factor receptor. The preferred anti-
angiogenic molecule herein binds to an receptor, preferably to an integrin receptor or
to VEGF receptor. The term includes according to the invention also a prodrug of said
angiogenic agent. There are a lot of molecules having different structure and origin
which elicit anti-agiogenic properties. Most relevant classes of angiogenesis
inhibitong or blocking agents which are suitable in this invention, are, for example:
(i) anti-mitotics such as flurouracil, mytomycin-C, taxol;
(ii) estrogen metabo!ites_such as 2-methoxyestradiol;
(iii) matrix metalloproteinase (MMP) inhibitors, which inhibit zinc
metalloproteinases (metalloproteases) (e.g. betimastat, BB16, TIMPs,
minocycline, GM6001, or those described in "Inhibition of Matrix Metalloproteinases:
Therapeutic Applications" (Golub, Annals of the New York Academy of Science, Vol.
878a; Greenwald, Zucker (Eds.), 1999);
(iv) anti-angiogenic multi-functional agents and factors such as IFNα
(US 4,530,901; US 4,503,035; 5,231,176); angiostatin and plasminogen fragments
(e.g. kringle 1-4, kringle 5, kringle 1-3 (O'Reilly, M. S. et al., Cell (Cambridge, Mass.)
79(2): 315-328, 1994; Cao et al., J. Biol. Chem. 271: 29461-29467, 1996; Cao et al.,
J. Biol Chem 272:22924 -22928,1997); endostatin (O'Reilly, M. S. et al., Cell 88(2),
277, 1997 and WO 97/15666), thrombospondin (TSP-1; Frazier,1991. Curr Opin Cell
Biol 3(5): 792); platelet factor 4 (PF4);

(v) plasminogen activator/urokinase inhibitors;
(vi) urokinase receptor antagonists;
(vii) heparinases;
(viii) fumagillin analogs such as TNP-470:
(ix) tyrosine kinase inhibitors such as SUI01 (many of the above and below -
mentioned ErbB receptor antagonists (EGFR / Her 2 antagonists) are also tyrosine
kinase inhibitors, and may show, therefore anti-EGF receptor blocking activity which
results in inhibiting tumor growth, as well as anti-angiogenic activity which results in
inhibiting the development of blood vessels and endothelial cells, respectively);
(x) suramin and suramin analogs;
(xi) angiostatic steroids;
(xii) VEGF and bFGF antagonists;
(xiii) VEGF receptor antagonists.such as anti-VEGF receptor antibodies (DC-101);
(xiv) flk-1 and flt-1 antagonists;
(xv) cyclooxxygenase-ll inhibitors such as COX-II;
(xvi) integrin antagonists and integrin receptor antagonists such as av
antagonists and αv receptor antagonists, for example, anti-αv receptor antibodies and
RGD peptides. Integrin (receptor) antagonists are preferred according to this
invention.
The term "integrin antagonists / inhibitors" or "integrin receptor antagonists /
inhibitors" refers to a natural or synthetic molecule that blocks and inhibit an integrin
receptor. In some cases, the term includes antagonists directed to the ligands of said
integrin receptors (such as for 0763." vitronectin, fibrin, fibrinogen, von Willebrand's
factor, thrombospondin, laminin; for αvβ5: vitronectin; for αvβ1: fibronectin and
vitronectin; for αvβ6: fibronectin). Antagonists directed to the integrin receptors are
preferred according to the invention. Integrin (receptor) antagonists may be natural or
synthetic peptides, non-peptides, peptidomimetica, immunoglobulins, such as
antibodies or functional fragments thereof, or immunoconjugates (fusion proteins).
Preferred integrin inhibitors of the invention are directed to receptor of αv integrins
(e.g. αvβ3, αvβ5, αvβ6 and sub-classes). Preferred integrin inhibitors are αv
antagonists, and in particular αvβ3 antagonists. Preferred αv antagonists according to

the invention are RGD peptides, peptidomimetic (non-peptide) antagonists and anti-
integrin receptor antibodies such as antibodies blocking αv receptors.
Exemplary, non-immunological αvβ3 antagonists are described in the teachings of US
5,753,230 and US 5,766,591. Preferred antagonists are linear and cyclic RGD-
containing peptides. Cyclic peptides are, as a rule, more stable and elicit an
enhanced serum half-life. The most preferred integrin antagonist of the invention is,
however, cyclo-(Arg-Gly-Asp-DPhe-NMeVal) (EMD 121974, Cilengitide®, Merck
KgaA, Germany; EP 0770 622) which is efficacious in blocking the integrin receptors
αvβ3, αvβ1, αvβ6, αvβ8, α11bβ3. Suitable peptidyl as well as peptidomimetic (non-
peptide) antagonists of the αvβ3/ αvβ5 / αvβ6 integrin receptor have been described
both in the scientific and patent literature. For example, reference is made to Hoekstra
and Poulter, 1998, Curr. Med. Chem. 5,195; WO 95/32710; WO 95/37655; WO
97/01540; WO 97/37655; WO 97/45137; WO 97/41844; WO 98/08840; WO
98/18460; WO 98/18461; WO 98/25892; WO 98/31359; WO 98/30542; WO
99/15506; WO 99/15507; WO 99/31061; WO 00/06169; EP 0853 084; EP 0854 140;
EP 0854 145; US 5,780,426; and US 6,048,861. Patents that disclose benzazepine,
as well as related benzodiazepine and benzocycloheptene avB3 integrin
receptor antagonists, which are also suitable for the use in this invention, include WO
96/00574, WO 96/00730, WO 96/06087, WO 96/26190, WO 97/24119, WO
97/24122, WO 97/24124, WO 98/15278, WO 99/05107, WO 99/06049, WO
99/15170, WO 99/15178, WO 97/34865, WO 97/01540, WO 98/30542, WO
99/11626, and WO 99/15508. Other integrin receptor antagonists featuring backbone
conformational ring constraints have been described in WO 98/08840; WO 99/30709;
WO 99/30713; WO 99/31099; WO 00/09503; US 5,919,792; US 5,925,655; US
5,981,546; and US 6,017,926. In US 6,048,861 and WO 00/72801 a series of
nonanoic acid derivatives which are potent αvβ3 integrin receptor antagonists were
disclosed. Other chemical small molecule integrin antagonists (mostly vitronectin
antagonists) are described in WO 00/38665. Other αvβ3 receptor antagonists have
been shown to be effective in inhibiting angiogenesis. For example, synthetic receptor
antagonists such as (S)-10.11-Dihydro-3-[3-(pyridin-2-ylamino)-1-propyloxy]-5H-
dibenzo[ a,d]cycloheptene-10-acetic acid (known as SB-265123) have been tested in
a variety of mammalian model systems. (Keenan et al., 1998, Bioorg. Med. Chem.

Lett. 8(22), 3171; Ward et al., 1999, Drug Metab. Dispos. 27(11),1232). Assays for
the identification of integrin antagonists suitable for use as an antagonist are
described, e.g. by Smith et al., 1990, J. Biol. Chem. 265,12267, and In the referenced
patent literature. Anti-integrin receptor antibodies are also well known. Suitable anti-
integrin (e.g. αvβ3, αvβ5, αvβ6) monoclonal antibodies can be modified to
encompasses antigen binding fragments thereof, including F(ab)2, Fab, and
engineered Fv or single-chain antibody. One suitable and preferably used monoclonal
antibody directed against integrin receptor αvβ3 is identified as LM609 (Brooks et al.,
1994, Cell 79, 1157; ATCC HB 9537). A potent specific anti-OvB5 antibody, P1F6, is
disclosed in WO 97/45447, which is also preferred according to this invention. A
further suitable αvβ6 selective antibody is MAb 14D9.F8 (WO 99/37683, DSM
ACC2331, Merck KGaA, Germany) as well as MAb 17.E6 (EP 0719 859, DSM
ACC2160, Merck KGaA) which is selectively directed to the αv- chain of integrin
receptors. Another suitable anti-integrin antibody is the commercialized Vitraxin ®.
The term "antibody" or "immunoglobulin" herein is used in the broadest sense and
specifically covers intact monoclonal antibodies, polyclonal antibodies, multispecific
antibodies (e.g. bispecific antibodies) formed from at least two intact antibodies, and
antibody fragments, so long as they exhibit the desired biological activity. The term
generally includes heteroantibodies which are composed of two or more antibodies or
fragments thereof of different binding specificity which are linked together.
Depending on the amino acid sequence of their constant regions, intact antibodies
can be assigned to different "antibody (Immunoglobulin) classes". There are five
major classes of intact antibodies: IgA, IgD, IgE, IgG, and IgM, and several of these
may be further divided into "subclasses" (isotypes), e.g., IgGl, lgG2, lgG3, lgG4, IgA,
and lgA2. The heavy-chain conscant domains that correspond to the different classes
of antibodies are called , δ, ε, γ and μ respectively. Preferred major class for
antibodies according to the invention is IgG, in more detail lgG1 and lgG2.
Antibodies are usually glycoproteins having a molecular weight of about 150,000,
composed of two identical light (L) chains and two identical heavy (H) chains. Each
light chain is linked to a heavy chain by one covalent disulfide bond, while the number
of disulfide linkages varies among the heavy chains of different immunoglobulin

isotypes. Each heavy and light chain also has regularly spaced intra-chain disulfide
bridges. Each heavy chain has at one end a variable domain (VH) followed by a
number of constant domains. The variable regions comprise hypervariable regions or
"CDR" regions, which contain the antigen binding site and are responsible for the
specificity of the antibody, and the "FR" regions, which are important with respect to
the affinity / avidity of the antibody. The hypervariable region generally comprises
amino acid residues from a "complementarity determining region" or "CDR" (e.g.
residues 24-34 (L1), 50-56 (L2) and 89-97 (L3) in the light chain variable domain and
31-35 (HI), 50-65 (H2) and 95-102 (H3) in the heavy chain variable domain; and/or
those residues from a "hypervariable loop" (e.g. residues 26-32 (L1 ), 50-52 (L2)
and 91-96 (L3) in the light chain variable domain and 26-32 (H1), 53-55 (H2) and 96-
101 (H3) in the heavy chain variable domain; Chothia and Lesk J. Mot. Biol. 196:901-
917 (1987)).The TR" residues (frame work region) are those variable domain
residues other than the hypervariable region residues as herein defined. Each light
chain has a variable domain at one end (VL) and a constant domain at its other end.
The constant domain of the light chain is aligned with the first constant domain of the
heavy chain, and the light-chain variable domain is aligned with the variable domain
of the heavy chain. Particular amino acid residues are believed to form an interface
between the light chain and heavy chain variable domains. The "light chains" of
antibodies from any vertebrate species can be assigned to one of two clearly distinct
types, called kappa (K) and lambda (X), based on the amino acid sequences of their
constant domains.
The term "monoclonal antibody" as used herein refers to an antibody obtained from
a population of substantially homogeneous antibodies, i.e., the individual antibodies
comprising the population are identical except for possible naturally occurring
mutations that may be present in minor amounts. Monoclonal antibodies are
highly specific, being directed against a single antigenic site. Furthermore, in contrast
to polyclonal antibody preparations which include different antibodies directed against
different determinants (epitopes), each monoclonal antibody is directed against a
single determinant on the antigen. In addition to their specificity, the monoclonal
antibodies are advantageous in that they may be synthesized uncontaminated by

other antibodies. Methods for making monoclonal antibodies include the hybridoma
method described by Kohler and Miistein (1975, Nature 256, 495) and in "Monoclonal
Antibody Technology, The Production and Characterization of Rodent and Human
Hybridomas" (1985, Burdon et al., Eds, Laboratory Techniques in Biochemistry and
Molecular Biology, Volume 13, Elsevier Science Publishers, Amsterdam), or may be
made by well known recombinant DNA methods (see, e.g., US 4,816,567).
Monoclonal antibodies may also be isolated from phage antibody libraries using the
techniques described in Clackson et al., Nature, 352:624-628 (1991) and Marks etal.,
J. Mol. Biol., 222:58, 1-597(1991), for example.
The term "chimeric antibody" means antibodies in which a portion of the heavy
and/or light chain is identical with or homologous to corresponding sequences in
antibodies derived from a particular species or belonging to a particular antibody class
or subclass, while the remainder of the chain(s) is identical with or homologous to
corresponding sequences in antibodies derived from another species or belonging to
another antibody class or subclass, as well as fragments of such antibodies, so long
as they exhibit the desired biological activity (e.g.: US 4,816,567; Morrison et al.,
Proc. Nat. Acad. Sci. USA, 81:6851-6855 (1984)). Methods for making chimeric and
humanized antibodies are also known in the art. For example, methods for making
chimeric antibodies include those described in patents by Boss (Celltech) and by
Cabilly (Genentech) (US 4,816,397; US 4,816,567).
"Humanized antibodies" are forms of non-human (e.g., rodent) chimeric antibodies
that contain minimal sequence derived from non-human immunoglobulin. For the
most part, humanized antibodies are human immunoglobulins (recipient antibody) in
which residues from a hypervariable region (CDRs) of the recipient are replaced by
residues from a hypervariable region of a non-human species (donor antibody) such
as mouse, rat, rabbit or nonhuman primate having the desired specificity, affinity and
capacity. In some instances, framework region (FR) residues of the human
immunoglobulin are replaced by corresponding non-human residues. Furthermore,
humanized antibodies may comprise residues that are not found in the recipient
antibody or in the donor antibody. These modifications are made to further refine

antibody performance. In general, the humanized antibody will comprise substantially
all of at least one, and typically two, variable domains, in which all or substantially all
of the hypervariable loops correspond to those of a non-human immunoglobulin and
all or substantially all of the FRs are those cf a human immunoglobulin sequence. The
humanized antibody optionally also will comprise at least a portion of an
immunoglobulin constant region (Fc), typically that of a human immunoglobulin.
Methods for making humanized antibodies are described, for example, by Winter (US
5,225,539) and Boss (Celltech, US 4,816,397).
"Antibody fragments" comprise a portion of an intact antibody, preferably
comprising the antigen-binding or variable region thereof. Examples of antibody
fragments include Fab, Fab', F(ab')2, Fv and Fc fragments, diabodies, linear
antibodies, single-chain antibody molecules; and multispecific antibodies formed from
antibody fragment(s). An "intact" antibody is one which comprises an antigen-binding
variable region as well as a light chain constant domain (CL) and heavy chain
constant domains, CH1, CH2 and CH3. Preferably, the intact antibody has one or
more effector functions. Papain digestion of antibodies produces two identical
antigen-binding fragments, called "Fab" fragments, each comprising a single antigen-
binding site and a CL and a CH1 region, and a residual "Fc" fragment, whose name
reflects its ability to crystallize readily. The "Fc" region of the antibodies comprises, as
a rule, a CH2, CH3 and the hinge region of an lgG1 or lgG2 antibody major class.
The hinge region is a group of about 15 amino acid residues which combine the CH1
region with the CH2-CH3 region. Pepsin treatment yields an "F(ab')2" fragment that
has two antigen-binding sites and is still capable of cross-linking antigen. "Fv" is the
minimum antibody fragment which contains a complete antigen-recognition and
antigen-binding site. This region consists of a dimer of one heavy chain and one light
chain variable domain in tight, non-covalent association. It is in this configuration that
the three hypervariable regions (CDRs) of each variable domain interact to define an
antigen-binding site on the surface of the VH - VL dimer. Collectively, the six hypervariable regions confer antigen-binding specificity to the antibody. However,
even a single variable domain (or half of an Fv comprising only three hypervariable
regions specific for an antigen) has the ability to recognize and bind antigen, although

at a lower affinity than the entire binding site. The Fab fragment also contains the
constant domain of the light chain and the first constant domain (CH1) of the heavy
chain." Fab'" fragments differ from Fab fragments by the addition of a few residues
at the carboxy terminus of the heavy chain CH1 domain including one or more
cysteines from the antibody hinge region. F(ab')2 antibody fragments originally were
produced as pairs of Fab' fragments which have hinge cysteines between them.
Other chemical couplings of antibody fragments are also known (see e.g. Hermanson,
Bioconjugate Techniques, Academic Press, 1996;. US 4,342,566). "Single-chain Fv"
or "scFv" antibody fragments comprise the V, and V, domains of antibody,
wherein these domains are present in a Single polypeptide chain. Preferably, the Fv
polypeptide further comprises a polypeptide linker between the VH and VL domains
which enables the scFv to form the desired structure for antigen binding. Single-chain
FV antibodies are known, for example, from Pluckthun (The Pharmacology of
Monoclonal Antibodies, Vol. 113, Rosenburg and Moore eds., Springer-Verlag, New
York, pp. 269-315 (1994)), W093/16185; US 5,571,894; US 5,587,458; Huston et al.
(1988, Proc.Natl. Acad. Sci. 85, 5879) or Skerra and Plueckthun (1988, Science 240,
1038).
"Bispecific antibodies" are single, divalent antibodies (or immunotherapeutically
effective fragments thereof) which have two differently specific antigen binding sites.
For example the first antigen binding site is directed to an angiogenesis receptor (e.g.
integrin or VEGF receptor), whereas the second antigen binding site is directed to an
ErbB receptor (e.g. EGFR or Her 2). Bispecific antibodies can be produced by
chemical techniques (see e.g., Kranz et al. (1981) Proc. Natl. Acad. Sci. USA 78,
5807), by "polydoma" techniques (See US 4,474,893) or by recombinant DNA
techniques, which all are known per se. Further methods are described in WO
91/00360, WO 92/05793 and WO 96/04305. Bispecific antibodies can also be
prepared from single chain antibodies (see e.g., Huston et al. (1988) Proc. Natl.
Acad. Sci. 85, 5879; Skerra and Plueckthun (1988) Science 240, 1038). These are analogues of antibody variable regions produced as a single polypeptide chain. To
form the bispecific binding agent, the single chain antibodies may be coupled together
chemically or by genetic engineering methods known in the art. It is also possible to

produce bispecific antibodies according to this invention by using leucine zipper
sequences. The sequences employed are derived from the leucine zipper regions of
the transcription factors Fos and Jun (Landschulz et al., 1988, Science 240,1759; for
review, see Maniatis and Abel, 1989, Nature 341,24). Leucine zippers are specific
amino acid sequences about 20-40 residues long with leucine typically occurring at
every seventh residue.. Such zipper sequences form amphipathic α-helices, with the
leucine residues lined up on the hydrophobic side for dimer formation. Peptides
corresponding to the leucine zippers of the Fos and Jun proteins form heterodimers
preferentially (O'Shea et al., 1989, Science 245, 646). Zipper containing bispecific
antibodies and methods for making them are also disclosed in WO 92/10209 and WO
93/11162. A bispecific antibody according the invention may be an antibody, directed
to VEGF receptor and αV33 receptor as discussed above with respect to the
antibodies having single specificity.
"Heteroantibodies" are two or more antibodies or antibody-binding fragments which
are linked together, each of them having a different binding specificity.
Heteroantibodies can be prepared by conjugating together two or more antibodies
or antibody fragments. Preferred heteroantibodies are comprised of cross-linked
Fab/Fab' fragments. A variety of coupling or crosslinking agents can be used
to conjugate the antibodies. Examples are protein A, carboiimide, N-succinimidyl-S-
acetyl-thioacetate (SATA) and N-succinimidyl-3-(2-pyridyldithio) propionate (SPDP)
(see e.g., Karpovsky et al. (1984) J. EXP. Med. 160,1686; Liu et a. (1985) Proc. Natl.
Acad. Sci. USA 82, 8648). Other methods include those described by Paulus, Behring
Inst. Mitt., No. 78, 118 (1985); Brennan et a. (1985) Science 30 m:81 or Glennie et al.
(1987) J. Immunol. 139, 2367. Another method uses o-phenylenedimaleimide
(oPDM) for coupling three Fab' fragments (WO 91/03493). Multispecific antibodies
are in context of this invention also suitable and can be prepared, for example
according to the teaching of WO 94/13804 and WO 98/50431.
The term "fusion protein" refers to a natural or synthetic molecule consisting of one
ore more proteins or peptides or fragments thereof having different specificity which
are fused together optionally by a linker molecule. As specific embodiment the term

includes fudsion constructs, wherein at least one protein or peptide is a
immunoglubulin or antibody, respectively or parts thereof ("immunoconjugates").
The term "immunoconjugate' refers to an antibody or immunoglobulin respectively,
or a immunologically effective fragment thereof, which is fused by covalent linkage to
a non-immunologically effective molecule. Preferably this fusion partner is a peptide
or a protein, which may be glycosylated. Said non-antibody molecule can be linked to
the C-terminal of the constant heavy chains of the antibody or to the N-terminals of
the variable light and/or heavy chains. The fusion partners can be linked via a linker
molecule, which is, as a rule, a 3 -15 amino acid residues containing peptide.
Immunoconjugates according to the invention consist of an immunoglobulin or
immunotherapeutically effective fragment thereof, directed to a receptor tyrosine
kinase, preferably an ErbB (ErbB1/ErbB2) receptor and an integrin antagonistic
peptide, or an angiogenic receptor, preferably an integrin or VEGF receptor and
TNFα or a fusion protein consisting essentially of TNFα and IFNγ or another suitable
cytokine, which is linked with its N-terminal to the C-terminal of said immunoglobulin,
preferably the Fc portion thereof. The term includes also corresponding fusion
constructs comprising bi- or multi-specific immunoglobulins (antibodies) or fragments
thereof.
The term "functionally intact derivative" means according to the understanding of
this invention a fragment or portion, modification, variant, homologue or a de-
immunized form (a modification, wherein epitopes, which are responsible for immune
responses, are removed) of a compound, peptide, protein, antibody (immunoglobulin),
immunconjugate, etc., that has principally the same biological and / or therapeutic
function as compared with the original compound, peptide, protein, antibody
(immunoglobulin), immunconjugate, etc. However, the term includes also such
derivatives, which elicit a reduced or enhanced efficacy.
The term "cytokine" is a generic term for proteins released by one cell population
which act on another cell as intercellular mediators. Examples of such cytokines are
lymphokines, monokines, and traditional polypeptide hormones. Included among the

cytokines are growth hormone such as human growth hormone, N-methionyl
human growth hormone, and bovine growth hormone; parathyroid hormone;
thyroxine; insulin; proinsulin; relaxin; prorelaxin; glycoprotein hormones such as
follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH), and luteinizing
hormone (LH); hepatic growth factor; fibroblast growth factor; prolactin; placental
lactogen; mouse gonadotropin-associated peptide; inhibin; activin; vascular
endothelial growth factor (VEGF); integrin; thrombopoietin (TPO); nerve growth
factors such as NGFβ; platelet-growth factor; transforming growth factors (TGFs)
such as TGFα and TGFβ; erythropoietin (EPO); interferons such as IFNα, JFNG, and
IFNγ; colony stimulating factors such as M-CSF, GM-CSF and G-CSF; interleukins
such as IL-1, IL-1a, IL-2, lL-3, iL-4, IL-5, IL-6, IL-7, IL-8, IL-9, 1L-10, IL-11,1L-12; and
TNFa or TNFS. Preferred cytokines according to the invention are interferons and
TNFa.
The term "cytotoxic agent" as used herein refers to a substance that inhibits or
prevents the function of cells and/or causes destruction of cells. The term is intended
to include radioactive isotopes, chemotherapeutic agents, and toxins such as
enzymatically active toxins of bacterial, fungal, plant or animal origin, or fragments
thereof. The term may include also members of the cytokine family, preferably IFNy
as well as antineoplastic agents having also cytotoxic activity.
The term "chemotherapeutic agent" or "anti-neopiastic agent" is regarded
according to the understanding of this invention as a member of the class of
"cytotoxic agents", as specified above, and includes chemical agents that exert anti-
neoplastic effects, i.e., prevent the development, maturation, or spread of neoplastic
cells, directly on the tumor cell, e.g., by cytostatic or cytotoxic effects, and not
indirectly through mechanisms such as biological response modification. Suitable
chemotherapeutic agents according to the invention are preferably natural or
synthetic chemical compounds, but biological molecules, such as proteins,
polypeptides etc. are not expressively excluded. There are large numbers of anti-
neoplastic agents available in commercial use, in clinical evaluation and in pre-
clinical development, which could be included in the present invention for treatment of

tumors / neoplasia by combination therapy with TNFα and the anti-angiogenic agents
as cited above, optionally with other agents such as EGF receptor antagonists. It
should be pointed out that the chernotherapeutic agents can be administered
optionally together with above-said drug combination. Examples of chernotherapeutic
or agents include alkylating agents, for example, nitrogen mustards, ethyleneimine
compounds, alkyl sulphonates and other compounds with an alkylating action such as
nitrosoureas, cisplatin and dacarbazine; antimetabolites, for example, folic acid,
purine or pyrimidine antagonists; mitotic inhibitors, for example, vinca alkaloids and
derivatives of podophyllotoxin; cytotoxic antibiotics and camptothecin
derivatives. Preferred chernotherapeutic agents or chemotherapy include
amifostine (ethyoi), cisplatin, dacarbazine (DTIC), dactinomycin, mechlorethamine
(nitrogen mustard), streptozocin, cyclophosphamide, carrnustine (BCNU), lomustine
(CCNU), doxorubicin (adriamycin), doxorubicin lipo (doxil), gemcitabine
(gemzar), daunorubicin, daunorubicin lipo (daunoxome), procarbazine, mitomycin,
cytarabine, etoposide, methotrexate, 5-fiuorouracil (5-FU), vinblastine, vincristine,
bleomycin, paclitaxel (taxoi), docetaxel (taxotere), aldesleukin, asparaginase,
busulfan, carboplatin, cladribine, camptothecin, CPT-11, 10-hydroxy-7-ethyl-
camptothecin (SN38), dacarbazine, floxuridine, fludarabine, hydroxyurea, ifosfamide,
idarubicin, mesna, interferon alpha, interferon beta, irinotecan, mitoxantrone,
topotecan, leuprolide, megestrol, melphalan, mercaptopurine, plicamycin, mitotane,
pegaspargase, pentostatin, pipobroman, plicamycin, streptozocin, tamoxifen,
teniposide, testolactone, thioguanine, thiotepa,. uracil mustard, vinorelbine,
chlorambucil and combinations thereof.
Most preferred chernotherapeutic agents according to the invention are cisplatin,
gemcitabine, doxorubicin, paclitaxel (taxol) and bleomycin.
The terms "cancer" and "tumor" refer to or describe the physiological condition in
mammals that is typically characterized by unregulated cell growth. By means of the
pharmaceutical compositions according of the present invention tumors can be
treated such as tumors of the breast, heart, lung, small intestine, colon, spleen,
kidney, bladder, head and neck, ovary, prostate, brain, pancreas, skin, bone, bone
marrow, blood, thymus, uterus, testicles, cervix, and liver. More specifically the tumor

is selected from the group consisting of adenoma, angio-sarcoma, astrocytoma,
epithelial carcinoma, germinoma, glioblastoma, glioma,
hamartoma, hemangioendothelioma, hemangiosarcoma, hematoma, hepato-
blastoma, leukemia, lymphoma, medulloblastoma, melanoma, neuroblastoma,
osteosarcoma, retinoblastoma, rhabdomyosarcoma, sarcoma and teratoma.
In detail, the tumor is selected from the group consisting of acral lentiginous
melanoma, actinic keratoses, adenocarcinoma, adenoid cycstic carcinoma,
adenomas, adenosarcoma, adenosquamous carcinoma, astrocytic tumors, bartholin
gland carcinoma, basal cell carcinoma, bronchial gland carcinomas, capillary,
carcinoids, carcinoma, carcinosarcoma, cavernous, cholangio-carcinoma,
chondosarcoma, choriod plexus papilloma/carcinoma, clear cell
carcinoma, cystadenoma, endodermal sinus tumor, endometrial hyperplasia,
endometrial stromal sarcoma, endometrioid adenocarcinoma, ependymal, epitheloid,
Ewing's sarcoma, fibrolamellar, focal nodular hyperplasia, gastrinoma, germ cell
tumors, glioblastoma, glucagonoma, hemangiblastomas, hemangioendothelioma,
hemangiomas, hepatic adenoma, hepatic adenomatosis, hepatocellular carcinoma,
insulinoma, intaepithelial neoplasia, interepithefial squamous cell neoplasia,
invasive squamous cell carcinoma, large cell carcinoma, leiomyosarcoma, lentigo
maligna melanomas, malignant melanoma, malignant mesothelial tumors,
medulloblastoma, medulloepithelioma, melanoma, meningeal, mesothelial, metastatic
carcinoma, mucoepidermoid carcinoma, neuroblastoma, neuroepithelial
adenocarcinoma nodular melanoma, oat cell carcinoma, oligodendroglial,
osteosarcoma, pancreatic polypeptide, papillary serous adeno-carcinoma, pineal cell,
pituitary tumors, plasmacytoma, pseudo-sarcoma, pulmonary blastoma, renal cell
carcinoma, retinoblastoma, rhabdomyo-sarcoma, sarcoma, serous carcinoma, small
cell carcinoma, soft tissue carcinomas, somatostatin-secreting tumor, squamous
carcinoma, squamous cell carcinoma, submesothelial, superficial spreading
melanoma, undifferentiated carcinoma, uveal melanoma, verrucous carcinoma,
vipoma, well differentiated carcinoma, and Wilm's tumor.
The "pharmaceutical compositions" of the invention can comprise agents that
reduce or avoid side effects associated with the combination therapy of the present

invention ("adjunctive therapy"), including, but not limited to, those agents, for
example, that reduce the toxic effect of anticancer drugs, e.g., bone resorption
inhibitors, cardioprotective agents. Said adjunctive agents prevent or reduce the
incidence of nausea and vomiting associated with chemotherapy, radiotherapy or
operation, or reduce the incidence of infection associated with the administration
of myelosuppressive anticancer drugs. Adjunctive agents are well known in the
art. The immunotherapeutic agents according to the invention can additionally
administered with adjuvants like BCG and immune system stimulators. Furthermore,
the compositions may include immunotherapeutic agents or chemotherapeutic agents
which contain cytotoxic effective radio labeled isotopes, or other cytotoxic agents,
such as a cytotoxic peptides (e.g. cytokines) or cytotoxic drugs and the like.
The term " pharmaceutical kit" for treating tumors or tumor metastases refers to a
package and, as a rule, instructions for using the reagents in methods to treat tumors
and tumor metastases. A reagent in a kit of this invention is typically formulated as a
therapeutic composition as described herein, and therefore can be in any of a variety
of forms suitable for distribution in a kit. Such forms can include a liquid, powder,
tablet, suspension and the like formulation for providing the antagonist and/or
the fusion protein of the present invention. The reagents may be provided in separate
containers suitable for administration separately according to the present methods, or
alternatively may be provided combined in a composition in a single container in the
package. The package may contain an amount sufficient for one or more dosages of
reagents according to the treatment methods described herein. A kit of this invention
also contains "instruction for use" of the materials contained in the package.
The term "pharmaceutical treatment" refers to therapeutic methods of the present
invention for treating tumor cells in tumors and tumor metastases are based on the
combined use of angiogenesis inhibiting (anti-angiogenesis) therapy and anti-
tumor immunotherapy by using receptor tyrosine kinase blocking agents, preferably
ErbB antagonists, above all anti-ErbB1(EGFR, Her1) /anti-ErbB2 (Her2) antibodies.
More than one type of angiogenesis inhibiting agent can be used in combination with
more than one type of preferably anti-ErbB receptor inhibiting agent. The combined

use can occur simultaneously, sequentially, or with the intervention of a period of time
between the treatments. Any of the specific therapeutics may be administered more
than once during a course of treatment. The method can result in a synergistic
potentiation of the tumor cell proliferation inhibition effect of each individual
therapeutic, yielding more effective treatment than found by administering an
individual component alone. Thus, in one aspect, the method of the invention
encompasses administering to a patient, in combination, an amount of an anti-
angiogenic agent and an anti-ErbB receptor (Her1/Her2) agent, that may not result in
effective angiogenesis inhibition, or anti-tumor cell activity if given in that amount
alone. The method of the invention comprises a variety of modalities for practicing the
invention in terms of the steps. For example, the agents according to the invention
can be administered simultaneously, sequentially, or separately. Furthermore, the
receptor tyrosine kinase blocking agent and the anti-angiogenic agent can be
separately administered within a time interval of about 3 weeks between
administrations, i.e., from substantially immediately after the first active agent is
administered to up to about 3 weeks after the first agent is administered. The method
can be practiced following a surgical procedure. Alternatively, the surgical procedure
can be practiced during the interval between administration of the first active agent
and the second active agent. Exemplary of this method is the combination of the
present method with surgical tumor removal. Treatment according to the method will
typically comprise administration of the therapeutic compositions in one or more
cycles of administration. For example, where a simultaneous administration is
practiced, a therapeutic composition comprising both agents is administered over a
time period of from about 2 days to about 3 weeks in a single cycle. Thereafter,
the treatment cycle can be repeated as needed according to the judgment of the
practicing physician. Similarly, where a sequential application is contemplated,
the administration time for each individual therapeutic will be adjusted to typically
cover the same time period. The interval between cycles can vary from about zero
to 2 months. The monoclonal antibodies, polypeptides or organic mimetics /
chemotherapeutics of this invention can be administered parenteral^ by injection or
by gradual infusion over time. Although the tissue to be treated can typically be
accessed in the body by systemic administration and therefore most often treated by

intravenous administration of therapeutic compositions, other tissues and delivery
means are contemplated where there is a likelihood that the tissue targeted contains
the target molecule. Thus, monoclonal antibodies, polypeptides or organic agents of
this invention can be administered intraocularly, intravenously, intraperitoneally,
intramuscularly, subcutaneously, intracavity, transdermally, by orthotopic injection and
infusion, and can also be delivered by peristaltic means. The therapeutic
compositions containing, for example, an integrin antagonist of this invention
are conventionally administered intravenously, as by injection of a unit dose, for
example. Therapeutic compositions of the present invention contain a physiologically
tolerable carrier together with the relevant agent as described herein, dissolved or
dispersed therein as an active ingredient.
As used herein, the terms "pharmaceutically acceptable" and grammatical
variations thereof, as they refer to compositions, carriers, diluents and reagents,
are used interchangeably and represent that the materials are capable of
administration to or upon a mammal without the production of undesirable
physiological effects such as nausea, dizziness, gastric upset and the like. The
preparation of a pharmacological composition that contains active ingredients
dissolved or dispersed therein is well understood in the art and need not be limited
based on formulation. Typically, such compositions are prepared as injectables either
as liquid solutions or suspensions, however, solid forms suitable for solution, or
suspensions, in liquid prior to use can also be prepared. The preparation can also be
emulsified. The active ingredient can be mixed with excipients which are
pharmaceutically acceptable and compatible with the active ingredient and in
amounts suitable for use in the therapeutic methods described herein. Suitable
excipients are, for example, water, saline, dextrose, glycerol, ethanol or the like and
combinations thereof. In addition, if desired, the composition can contain minor
amounts of auxiliary substances such as wetting or emulsifying agents., pH buffering
agents and the like which enhance the effectiveness of the active ingredient. The
therapeutic composition of the present invention can include pharmaceutically
acceptable salts of the components therein. Pharmaceutically acceptable salts
include the acid addition salts (formed with the free amino groups of the polypeptide)
that are formed with inorganic acids such as. for example, hydrochloric or phosphoric

acids, or such organic acids as acetic, tartaric, mandelic and the like. Salts formed
with the free carboxyl groups can also be derived from inorganic bases such as, for
example, sodium, potassium, ammonium, calcium or ferric hydroxides, and such
organic bases as isopropylamine, trimethylamine, 2-ethylamino ethanol, histrdine,
procaine and the like. Particularly preferred is the HCI salt when used in the
preparation of cyclic polypeptide αv antagonists. Physiologically tolerable carriers are
well known in the art. Exemplary of liquid carriers are sterile aqueous solutions that
contain no materials in addition to the active ingredients and water, or contain a buffer
such as sodium phosphate at physiological pH value, physiological saline or both,
such as phosphate-buffered saline. Still further, aqueous carriers can contain more
than one buffer salt, as well as salts such as sodium and potassium chlorides,
dextrose, polyethylene glycol and other solutes. Liquid compositions can also contain
liquid phases in addition to and to the exclusion of water. Exemplary of such
additional liquid phases are glycerin, vegetable oils such as cottonseed oil, and water-
oil emulsions.
Typically, a therapeutically effective amount of an immunotherapeutic agent in the
form of a, for example, anti-ErbB receptor antibody or antibody fragment or antibody
conjugate or an anti-angiogenic receptor antibody, fragment or conjugate is an
amount such that when administered in physiologically tolerable composition is
sufficient to achieve a plasma concentration of from about 0.01 microgram (μg) per
milliliter (ml) to about 100 μg/ml, preferably from about 1 ng/ml to about 5 μg/ml and
usually about 5 μg/ml. Stated differently, the dosage can vary from about 0.1 mg/kg to
about 300 mg/kg, preferably from about 0.2 mg/kg to about 200 mg/kg, most
preferably from about 0.5 mg/kg to about 20 mg/kg, in one or more dose
administrations daily for one or several days. Wnere the immunotherapeutic agent is
in the form of a fragment of a monoclonal antibody or a conjugate, the amount can
readily be adjusted based on the mass of the fragment / conjugate relative to the
mass of the whole antibody. A preferred plasma concentration in molarity is from
about 2 micromolar (μM) to about 5 millimolar (mM) and preferably, about 100 μM to
1 mM antibody antagonist. A therapeutically effective amount of an agent according of
this invention which is a non-immunotherapeutic peptide or a protein polypeptide (e.g.

IFN-alpha), or other similarly-sized small molecule, is typically an amount of
polypeptide such that when administered in a physiologically tolerable composition
is sufficient to achieve a plasma concentration of from about 0.1 microgram (μg) per
milliliter (ml) to about 200 μg/ml, preferably from about 1 μg/ml to about 150 ng/ml.
Based on a polypeptide having a mass of about 500 grams per mole, the preferred
plasma concentration in molarity is from about 2 micromolar (μM) to about 5
millimolar (mM) and preferably about 100 ΜM to 1 mM polypeptide antagonist. The
typical dosage of an active agent, which is a preferably a chemical antagonist or a
(chemical) chemotherapeutic agent according to the invention (neither an
immunotherapeutic agent nor a non-immunotherapeutic peptide/protein) is 10 mg to
1000 mg, preferably about 20 to 200 mg, and more preferably 50 to 100 mg per
kilogram body weight per day.
The term "therapeutically effective" or "therapeutically effective amount" refers to
an amount of a drug effective to treat a disease or disorder in a mammal. In the case
of cancer, the therapeutically effective amount of the drug may reduce the number of
cancer cells; reduce the tumor size; inhibit (i.e., stow to some extent and preferably
stop) cancer cell infiltration into peripheral organs; inhibit (i.e., slow to some extent
and preferably stop) tumor metastasis; inhibit, to some extent, tumor growth; and/or
relieve to some extent one or more of the symptoms associated with the cancer. To
the extent the drug may prevent growth and/or kill existing cancer cells, it may be
cytostatic and/or cytotoxic. For cancer therapy, efficacy can, for example, be
measured by assessing the time to disease progression (TTP) and/or determining the
response rate (RR).
Example: The following is a short clinical trial report:
A patient, 45 years old, was originally suffering from progressive squamous cell
carcinoma of the superior maxilla.
EMD 72000: Monoclonal human antibody 425 (h425), Merck KgaA, Germany
EMD 121974: Cyclo-(Arg-Gly-Asp-DPhe-NMeVal), Cilengitide®, Merck KgaA,
Germany;

Chemotherapeutics: various (gemcitabine, cisplatin, etc.)
Case history and clinical findings/status at the start of the compassionate use
treatment: In July 1997 the patient first presented at the Virchow Klinikum, Germany.
A biopsy of the suspected large tumor in the upper maxilla was performed. Histology
revealed a squamous cell carcinoma classified as T4 ,N0 MO. On August 5,1997
partial resection of the superior maxilla and resection of regional lymph nodes was
done. Histology revealed that no clean margin had been achieved, so an additional
resection was performed during the same hospital stay. Due to the unfavourable
histologic classification the patient received a post-operative radiation therapy up to
50.4 Gray from September to October 1997.
In July 1998 progression of disease was suspected which led to hospitalization.
Histology now showed an adenosquamous carcinoma. After consultation of
radiotherapists another radiotherapy was recommended which started in August
1998. The patient was treated simultaneously with gemcitabine (100 mg) as a
radiosensitizer. The 6 week-therapy led to complete clinical remission. Following the
combined radio-chemotherapy the patient received a therapy with 1000 mg
gemcitabine (5 circles of 16 administrations).
In March 1999 again progression of the carcinoma occurred which led to additional
radiation therapy and palliative resection of the tumor. In August 1999 again tumor
progression and chemotherapy with cisplatin (75 mg/m2) and docetaxel (75 mg/m2)
was started. After three administrations the therapy was stopped due to lack of effect
on tumor growth.
Diffuse bleedings out of the large tumor mass required frequent transfusions of
erythrocyte concentrates.
Course of compassionate use treatment with anti-anqioqenic agent /
chemotherapeutic agents: Under treatment with EMD 121974 (600 mg/m2) and
gemcitabine (Gemzar) (1000mg /m2) in November 1999 a regression of the tumor
was diagnosed. Since mid of January 2000 the patient had been able to hear again
on his right ear and he had been able to open his mouth 30% more than in December
1999. The surface of the tumor showed signs of granulation and wound healing.
Bleeding stopped and there was no need for further transfusions.

The patient was treated with EMD 121974 and Gemzar from 17.11.1999 until
30.03.2000. From 06.04.2000 until 28.04.2000 EMD 121974, Gemzar and a
chemotherapy with 5-FU,cisplatin and rescuvolin was given to the patient because a
progression of the tumor was detected. Chemotherapy-treatment was stopped
because of haematotoxicity and Citengitide treatment was continued alone. From
April to June 2000 the patient received 600 mg/m2 EMD 121974 twice a week only
resulting in stable disease.
The patient's condition worsened after several weeks and the patient was treated .
with an increased dose of 1200 mg/m2 EMD 121974 twice weekly.
Treatment with h425 + Cilenqitide + chemotherapeutics: EMD 72000 was first given in
November 2000 in a dosage of 200 mg (infusion over half an hour) after
premedication with dexamethasone / dimetindenmaleate ( Fenistil) and ranitidin
(Zantic). One week later the patient received additionally gemcitabine (1000mg/m2).
The weekly treatment schedule was : Monday: 1200mg/m2 Cilengitide (one hour
infusion),Thursday 200 mg EMD 72 000 (half an hour infusion) followed by
1000mg/m2 gemcitabine (one hour infusion), Friday 1200 mg/m2 Cilengitide (one hour
infusion). Under this treatment a crater-like disintegration of the tumor mass was
observed. The tumor masses were surgically removed at several occasions. The
effect of the combined treatment was considered exceptionally impressive by the
treating physicians. No therapy related adverse drug reactions in relation to EMD
121974 and EMD 72000 were observed. Up to now the patient's condition remained
improved.

WE CLAIM:
1. A pharmaceutical composition comprising
(i) at least an antibody or an antibody fragment comprising a binding site which binds to an
epitope of the ErbB1 (Her1) receptor, said antibody is selected from the group consisting of
humanized monoclonal anti-EGFR antibody 425. and chimeric monoclon anti EGFR.
antibody 225. and
(ii) at least one second agent having an angiogenesis inhibiting specificity, wherein said
second agent is an avB3, avB5, or avB6 integrin-inhibiting ROD-containing linear or cyclic
peptide,
optionally together with a pharmaceutically acceptable carrier, diluent or recipient.
2. A pharmaceutical composition as claimed in claim 1, wherein said RGD-containing peptide
is cyclo(Arg'Gly-Asp-DPhe-NMeVal).
3. A pharmaceutical composition as claimed in claim, 1, comprising a chemotherapeutic agent
selected from the group consisting of: cisplatin, doxorubicin, gemcitabine, docetaxel,
paclitaxel, bleomycin.
4. A pharmaceutical kit comprising
(i) a first package comprising at least an antibody or an antibody fragment comprising a
binding site which binds to an epitope of the ErbBl(Herl) receptor, said antibody is selected
from the group consisting of humanized monoclonal anti-EGFR antibody 425, and chimeric
monoclonal anti-EGFR antibody 225., and
(ii) an agent having an angiogenesis inhibiting specificity, wherein said agent is an avB3, avB5
or avB6 integrm-inhibiting RGD-containing linear or cyclic peptide.
5. A pharmaceutical kit as claimed in claim 4, wherein said RGD-containing peptide is
cyclo(Arg-Gly-Asp-DPhe-NMeVal).
6. A pharmaceutical kit as claimed in claim 4 or 5 comprising a third package comprising a
chemotherapeutic agent selected from the group consisting of cisplatin, doxorubicin,
gemcitabine, docetaxel, paclitaxel, bleomycin.

The invention relates to a combination therapy for the
treatment of tumors and tumor metastases comprising
administration of receptor tyrosine kinase
antagonists/inhibitors, especially ErbB receptor
antagonists, more preferably EGF receptor (Her
1)antagonists and anti-angiogenic agents, preferably
integrin antagonists, optionally together with agents or
therapy forms that have additive or synergistic efficacy
when administered together with said combination of
antagonists/inhibitors, such as chemotherapeutic agents and
or radiation therapy. The therapy can result in a
synergistic potential increase of the inhibition effect of
each individual therapeutic on tumor cell proliferation,
yielding more affective treatment than found by
administering an individual component alone.

Documents:

992-KOLNP-2003-FORM-27-1.1.pdf

992-KOLNP-2003-FORM-27.pdf

992-kolnp-2003-granted-abstract.pdf

992-kolnp-2003-granted-claims.pdf

992-kolnp-2003-granted-correspondence.pdf

992-kolnp-2003-granted-description (complete).pdf

992-kolnp-2003-granted-examination report.pdf

992-kolnp-2003-granted-form 1.pdf

992-kolnp-2003-granted-form 18.pdf

992-kolnp-2003-granted-form 2.pdf

992-kolnp-2003-granted-form 3.pdf

992-kolnp-2003-granted-form 5.pdf

992-kolnp-2003-granted-gpa.pdf

992-kolnp-2003-granted-reply to examination report.pdf

992-kolnp-2003-granted-specification.pdf

992-kolnp-2003-granted-translated copy of priority document.pdf

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Patent Number

227633

Indian Patent Application Number

992/KOLNP/2003

PG Journal Number

03/2009

Publication Date

16-Jan-2009

Grant Date

14-Jan-2009

Date of Filing

01-Aug-2003

Name of Patentee

MERCK PATENT GMBH

Applicant Address

FRANKFURTER STRASSE 250, 64293 DARMSTADT

Inventors:

#	Inventor's Name	Inventor's Address
1	GOODMAN, SIMON	FRIEDRICH-EBERT-STRASSE 102A, 64327 GRIESHEIM
2	KREYSCH, HANS-GEORG	BURGUNDERWEG 16 55130 MAINZ

PCT International Classification Number

A61K 39/395

PCT International Application Number

PCT/EP2001/15241

PCT International Filing date

2001-12-21

PCT Conventions:

#	PCT Application Number	Date of Convention	Priority Country
1	01100507.1	2001-01-09	EPO