Treatment of primary CNS lymphoma with induction high-dose methotrexate, temozolomide, rituximab followed by consolidation cytarabine/etoposide: A pilot study with biomarker analysis

7595

Background: There is currently no consensus on the optimal treatment for patients diagnosed with primary CNS lymphoma (PCNSL). Between 2001–2004, UCSF PCNSL patients were treated with combination high-dose methotrexate, temozolomide, rituximab (MTR) as induction therapy. Patients in CR with this regimen were treated with high-dose cytarabine plus etoposide as consolidation. The purposes of this study were: (1) Pilot analysis to determine the safety and efficacy of intensive methotrexate-based induction therapy followed by high-dose consolidation with elimination of whole brain irradiation; (2) Analysis of molecular markers in PCNSL which predict sensitivity to chemotherapy and outcome. Methods: 21 untreated, CD20 +, immunocompetent PCNSL patients were treated with combination methotrexate (8 gm/m²), temozolomide (150 mg/m²/day)and rituximab (375 mg/m²). Patients in CR received consolidation cytarabine (2 g/ m² x 8 doses) plus etoposide (40 mg/kg over 96 hours). IHC analysis of potential biomarkers predictive of outcome was performed on paraffin sections from these patients. Candidate markers for validation were selected by gene expression analysis of an independent, multicenter dataset of 20 cases. Results: Mean age was 58.6 y (range 40–81). Median KPS was 60. MTR and cytarabine/etoposide consolidation was well-tolerated with no treatment-related mortality or evidence for neurotoxicity. One case of post-remission cytopenia occurred after consolidation and resolved spontaneously. Eleven patients (52.4%) attained CR with induction; eight received consolidation; three patients in CR deferred consolidation. Median PFS was 11.5 months. Median OS for all 21 patients has not yet been reached with median follow-up of 27.5 months. Expression of the apoptotic regulator DAP-1 by lymphoma cells as determined by IHC was associated with improved PFS (p<0.028) and OS (p<0.021). Conclusions: Combination MTR followed by intensive consolidation appears to be well tolerated in PCNSL. PFS appears at least similar to regimens that contain whole brain irradiation. A larger phase II study has been initiated to evaluate this regimen in a multicenter setting.

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Randomized single institute pilot study of vaccinia-CEA(6D)-tricom and fowlpox-CEA (6D)-tricom with GM-CSF (V) in combination with docetaxel (D) in patients with colorectal cancer (CC)

13538

Background: Our previous study demonstrated 40% patients with CC achieved stable disease at 4 months with V (JCO, 23(4):720–31, 2005.). Preclinical studies showed taxene enhanced tumor vaccine in delaying tumor growth and increasing the antigen-specific T cells. We report the results of a Randomized phase II pilot study of V in combination with docetaxel (D) in CC patients. Methods: 27 patients with metastatic CC were randomly assigned to 3 arms, stratified for HLA-A2. All patients received a ‘prime’ dose of vaccinia-Tricom on Day 0, followed by ‘boost’ doses of fowlpox-Tricom on Days 21 and q 21 days for 4 months; all vaccinations were followed by local GM-CSF (100 μg) for 4 days. Arm 1 received V; Arm II and III received V and D on D1, D8 during each fowlpox vaccination at 10mg/m2 and 30mg/m2, respectively. Patients with stable disease continued vaccinations monthly after study completed. Safety data was evaluated. Primary endpoints included the impact of varying doses of D on CEA-specific T cell immune responses (CTL) using the ELISPOT assay, the recommended dose for further study as defined by the best immune response with acceptable toxicity, and objective clinical response. Results: The most common AE related to the vaccines was grade (g) 1 injection site reactions. Other common AEs were g1 fatigue, nausea, vomiting, fever, headache, and myalgia. There were 1 g3 fever and 1 g3 abdominal pain. The AE from the combination arm were contributed by D as expected, included g3: hyperglycemia (1), fatigue (1), elevation of liver function tests (2), pulmonary infection (1), abdominal pain (1), vomiting (1) or diarrhea (1). 6/ 27 patients have died 17 months after starting V. Patients received 2 to 12 cycles of therapy before disease progression. Observed clinical benefit was significantly lower than the 40% previously documented with V alone. The immune data is to be presented. Conclusions: Inferior clinical benefit as compared to our previous experiment could be explained by more heavily pretreated patients in this trial or negative impact of D on V. CTL data should explain this observation.

No significant financial relationships to disclose.

First-in-human phase-I pharmacokinetic trial of NS-9, a liposomal poly(I):poly(C), in patients with liver metastases from various primary cancers

13016

Background: NS-9 is a complex of poly-inosinate [poly(I)] and poly-cytidylate [poly(C)] in a cationic liposome and is active in vitro and in vivo. Objectives: to determine the tolerability, safety, and maximal tolerated dose (MTD), and pharmacokinetics of NS-9 by 1 hr IV infusion, given daily x5 q 28 days. Methods: A phase I dose escalation study was undertaken in patients with liver metastases from solid tumors. Eligible patients were adults with ECOG PS 0–1 and no recent chemotherapy (≥ 4 wks prior). Dose cohorts studied were 0.1, 0.15, 0.2, 0.3 and 0.4mg/m2. Results: 18 patients were enrolled (13M:5F) median age 58 (range 21 to 77 yrs). Tumor types included neuroendocrine (8), and ocular melanoma (1), gastric (1), GE junction (1), esophageal (2), and colorectal (5) carcinomas. Two of three patients treated at the first dose level (0.4 mg/m2) had grade 3/4 reversible lipase elevation with or without acute pancreatitis, a dose limiting toxicity (DLT). De-escalation to doses ranging from 0.1 to 0.2 mg/m2/day was with no DLT. At 0.3 mg/m2 two of three patients treated had a DLT (neutropenia and thrombocytopenia). The MTD was determined at 0.2 mg/m2. Common toxicities included pyrexia, chills, nausea, fatigue, abdominal pain, myalgia, anorexia, sweating, neutropenia, thrombocytopenia, and elevated glucose, amylase, and LFTs. Pharmacokinetics showed rapid elimination (T1/2 ranged from 2.4 to 5.0 hours) without accumulation after multiple doses. 1 patient (esophageal Ca) had a PR in the target lesions in the liver. Conclusions: The MTD is 0.2 mg/m2/day with a hint of antitumor activity. NS-9 should be pursued in phase-II studies.

No significant financial relationships to disclose.

Phase I study of RX-0201 in patients with advanced or metastatic solid tumors

13102

Background: RX-0201 is a 20-mer oligonucleotide that is complementary to Akt-1 mRNA. Strong evidence exists that Akt plays a very important role in cancer progression by stimulating cell proliferation and inhibiting apoptosis. Over-expression of constitutively activated Akt in many cell types promotes cellular transformation. In addition to reducing Akt mRNA levels and inhibiting the expression of Akt protein, in vitro pharmacology studies have demonstrated that RX-0201 suppressed cell proliferation in carcinomas of the brain, breast, cervix, colon, head & neck, kidney, liver, lung, ovary, pancreas, prostate, stomach and melanoma. In vivo studies have also shown that RX-0201 significantly inhibits the growth of tumor in human prostate and brain cancer of nude mice models. This study is designed to determine the maximum tolerated RX-0201 dose in patients with advanced malignancies. Methods: Patients with solid tumors for whom no standard therapies exist, Karnofsky PS>70, adequate hepatic and renal function and normal coagulation parameters were eligible. Eligible patients were scheduled to receive 2 treatment cycles with RX-0201 via continuous infusion for 14 days with 7 days off q 21 days. Dose escalation was based on observed treatment-related toxicities. One patient was enrolled at each dose level (6 mg/m2/day - 315mg/m2/day). Tumor measurements were performed at screening and at the completion of treatment cycle 2. Tumor biopsies were obtained at screening and at the completion of treatment cycle 2 to look for inhibition of AKT in tumor cells. Plasma samples for pharmacokinetic analyses were collected. Results: To date 9 patients have been enrolled, 4 with GI malignancies, 1 with small cell lung cancer, 2 with breast cancer and 1 with locally advanced Basal Cell carcinoma. 6/9 patients were able to complete the 2 cycles.1/9 patients were taken off study because of withdrawal of consent due to grade 1 vomiting. 8 patients were taken off for disease progression. Drug related toxicities were Grade 1 and included fatigue, dizziness, cough vomiting and myalgia. Conclusions: While enrolment is still ongoing, the RX-0201 has been well tolerated upto 315mg/m2 in this previously heavily treated patient population. Once MTD is reached phase II trials will be planned. PK and PD data will be presented.

[Table: see text]

A phase I study of the pan-Bcl2 family inhibitor GX15–070, administered as a 3-hour weekly infusion in patients with refractory solid tumors or lymphomas

3081

Background: GX15–070 is an antagonist of the BH3-binding groove of the bcl-2 family of anti apoptotic proteins. GX15–070 activates apoptosis in vitro and exhibits clinical activity in chronic lymphocytic leukemia (O’Brien et al, ASH 2005) with a recommended phase II dose of 28 mg/m2 every 3 weeks with DLT of grade 3 infusional CNS toxicities. Methods: In a standard titration design, 4 cohorts of 3 patients (pt) were treated with 5mg/m2 - 14 mg/m2 IV infused over 3 hours, weekly. Each cycle of therapy consisted of 4 weekly infusions. Pharmacokinetics (PK) and pharmacodynamic (PD) response based on plasma oligonucleosomal DNA levels were evaluated. Results: N=15 pts were treated. Median age was 58 (range 24–71). Median number of prior regimens was 4 (range 1–11). A total of 105 infusions (26 cycles) was administered. GX15–070 underwent first order elimination kinetics with a short initial distribution phase (α t1/2=0.6 h), followed by a longer elimination γphase (t1/2=43.8 h). At the 14 mg/m2 dose level, median C max and AUC values were 98 ng/ml and 276 ng.hr/ml, respectively. The coefficient of variation was low at 38%. Adverse events have mostly been observed during or shortly after the infusion and have been transient. The most common pertain to the central nervous and gastro-intestinal system (drowsiness, euphoria, ataxia, and abdominal pain). Most toxicities were mild to moderate, with the exception of grade 3 pain experienced by 2/2 pts with Hodgkin’s disease, that resolved rapidly but resulted in treatment discontinuation in 1 patient. One episode of Grade 3 infusional CNS toxicity was reported at 14 mg/m2 requiring the inclusion of 6 patients with no further DLT. No neutropenia, thrombocytopenia or lymphopenia have been reported. The MTD has not been reached. Mean increase in plasma oligonucleosomal DNA was 36 fold (range 0–182 fold) over baseline. Best response to treatment to date : SD ≥ 8 weeks (4); PD (5); too early (6). Conclusion: Weekly GX15–070 as been well tolerated at doses showing biological activity. Dose escalation will be pursued up to 28 mg/m2 weekly.

No significant financial relationships to disclose.

A phase I dose escalation study of BIBW 2992, an irreversible dual EGFR/HER2 receptor tyrosine kinase inhibitor, in a 3 week on 1 week off schedule in patients with advanced solid tumors

3091

Background: BIBW 2992 is a highly potent irreversible dual EGFR /HER2 receptor tyrosine kinase inhibitor. This is the first trial performed in the United States with this compound. Methods: Patients with refractory solid tumors (historically known to express EGFR and/or HER2) with normal end-organ function and PS 0–1 were enrolled into a phase I dose-escalation clinical trial. After completion of eligibility and informed consent, BIBW 2992 was administered orally, once daily, for 21 days followed by a 7-day rest. Three patients were accrued in each cohort using a traditional dose escalation 3+3 trial design. After reaching DLT, the MTD dose group was expanded to 18 patients. PK sampling and skin biopsies were performed at baseline and day 21. Tumor biopsies in appropriate patients were obtained pre- and post-treatment in the final cohort to analyze inhibition of the EGFR pathway. Results: Forty-three patients were enrolled. Dose levels ranged from 10 to 65 mg daily. Tumor types included colon (10), breast (8), pancreas and ovarian (4), thyroid and esophageal (3), prostate and NSCLC (2), gastric, cholangiocarcinoma, basal cell, parotid, NPC, HCC, and mesothelioma (1 ). An interim PK analysis showed that BIBW 2992 exposure and peak plasma concentrations increased with increasing dose on day 1 and at steady state. Steady state was reached at day 8. Adverse events were diarrhea, skin rash, pruritus, mucositis, nausea, and vomiting. Doses were escalated to 65 mg/day, with two DLTs noted (skin rash and mucositis). The 40-mg dose was chosen as the recommended phase II dose based on acceptable toxicity when administered chronically. No objective responses have been observed; however, 15 of 35 evaluable patients (43%) experienced stable disease and have been on treatment for > 3 mos. Four patients have continued in an extension study. Two of these patients are still active and one has been taking BIBW 2992 for approximately 1 year. Conclusion: BIBW 2992 is well tolerated at 40 mg per day using a 21-day, 7-day off-treatment schedule. The adverse events observed were typical of receptor tyrosine kinases, including skin rash, pruritis, mucositis and GI disturbance.

[Table: see text]

Magnetic resonance spectroscopy for measuring the biodistribution and in situ in vivo pharmacokinetics of fluorinated compounds: validation using an investigation of liver and heart disposition of tecastemizole

BACKGROUND AND OBJECTIVE

The study of biodistribution and in situ pharmacokinetics is a challenging, but sometimes very important, aspect of premarketing characterization of drugs. We aimed to develop a non-invasive fluorine magnetic resonance (MR) spectroscopic method for the absolute quantitation of a mono-fluorinated compound and of its metabolites in the heart and liver of healthy subjects for this purpose.

METHOD

We used fluorine MR spectroscopy (MRS) at 4 T (Tesla) and external standardization in an open label multiple-dose study. Twenty-three healthy adult subjects were enrolled in the study. The surface coil localized fluorine MR spectrum was monitored in the heart and liver at baseline and after oral administration of multiple doses of tecastemizole. Steady-state measurements were made at set time points that depended upon dose, and washout measurements were made only on subjects in which in vivo fluorine signal was observed.

RESULTS AND DISCUSSION

At 4 T, under the given experimental conditions, the method had a lower limit of quantitation (LLOQ) of about 2.6 microm and a limit of detection (LOD) of about 0.3 microm for solution state samples (linewidth approximately 15 Hz). The measurement reproducibility was 6.4% using a 50 microm phantom. The effect of MR operator and spectral analyst on the calculated calibration curve slope was small, with inter-rater correlation coefficients of 0.999 and 0.998 respectively. MR signal from fluorine-containing tecastemizole-related moieties was observed in situ only at day 8 in the liver of three of five subjects dosed at 270 mg/day. The average in situ concentration was estimated to be 58+/-22 microm, with an average test-retest reproducibility of 216%. Extrapolating the in vitro results to human measurements, with an approximate linewidth of 250 Hz, predicts in situ LOD and LLOQ values of approximately 6 and 44 microm respectively. However, the human study had a fluorine MRS LOD of approximately 20 microm. The decrease in sensitivity and the increase in variability of the in vivo, in situ measurements compared with the validation study most likely arose from coil placement and incomplete rephasing of the MR signal by the respiratory phase compensation method.

CONCLUSION

The measured concentrations were the lowest ever recorded for a multi-dose exogenous mono-fluorinated compound in the human liver using a validated fluorine MR quantitation method. The proposed non-invasive MR method for studying the biodistribution and in situ pharmacokinetics of mono-fluorinated compounds in the liver and heart should have broader application to the development of non-invasive biomarkers.

Comparison of alfetanil and ketamine in combination with propofol for patient-controlled sedation during fiberoptic bronchoscopy

BACKGROUND

During fiberoptic bronchoscopy, propofol, ketamine, benzodiazepines, and opiates are most commonly used, alone or in combination for sedation. The aim of this study was to compare the clinical efficacy of propofol/ketamine with propofol/alfentanil for patient-controlled sedation (PCS) during fiberoptic bronchoscopy.

METHOD

Patients undergoing fiberoptic bronchoscopy were randomly assigned to receive either propofol/alfentanil (PA group; n = 138) or propofol/ketamine (PK group; n = 138) via a patient-controlled analgesia (PCA) device for sedation and analgesia. Changes in blood pressure, heart rate (HR), and oxygen saturation were monitored. Degree of patient and bronchoscopist satisfaction was evaluated using a 10-cm visual analog scale (VAS) (0 = extremely uncomfortable to 10 = extremely comfortable).

RESULTS

After sedation, systolic arterial pressure (SAP) decreased in the PA group, but SAP was stable in the PK group. Compared with values immediately before starting bronchoscopy, SAP and HR increased during the procedure in both groups (P < 0.05). Patients in the PK group showed more satisfaction [(9.5 (6-10) vs. 9.0 (6-10)), P < 0.05] and amnesia (82% vs. 61%, P < 0.01). Despite these differences, the majority (greater than 90%) of the patients in both groups stated that they were comfortable during the procedure.

CONCLUSION

Our results show that although both techniques proved effective for sedation in patients undergoing fiberoptic bronchoscopy, ketamine is superior to alfentanil when used in combination with propofol because of the high patient satisfaction and amnesia.

Serum CA19-9 response as a surrogate for clinical outcome in patients receiving fixed-dose rate gemcitabine for advanced pancreatic cancer

The use of serial serum measurements of the carbohydrate antigen 19-9 (CA19-9) to guide treatment decisions and serve as a surrogate end point in clinical trial design requires further validation. We investigated whether CA19-9 decline represents an accurate surrogate for survival and time to treatment failure (TTF) in a cohort of 76 patients with advanced pancreatic cancer receiving fixed-dose rate gemcitabine in three separate studies. Statistically significant correlations between percentage CA19-9 decline and both overall survival and TTF were found, with median survival ranging from 12.0 months for patients with the greatest degree of biomarker decline (>75%) compared with 4.3 months in those whose CA19-9 did not decline during therapy (P<0.001). Using specific thresholds, patients with ⩾25% decline in CA19-9 during treatment had significantly better outcomes than those who did not (median survival and TTF of 9.6 and 4.6 months vs 4.4 and 1.5 months; P<0.001). Similar results were seen using both 50 and 75% as cutoff points. We conclude that serial CA19-9 measurements correlate well with clinical outcomes in this patient population, and that decline in this biomarker should be entertained for possible use as a surrogate end point in clinical trials for the selection of new treatments in this disease.