1
|
Machover D, Almohamad W, Castagné V, Desterke C, Gomez L, Goldschmidt E. Treatment of patients with carcinomas in advanced stages with 5-fluorouracil, folinic acid and pyridoxine in tandem. Sci Rep 2024; 14:12054. [PMID: 38802419 PMCID: PMC11130240 DOI: 10.1038/s41598-024-62860-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
The effect of high-dose pyridoxine (PN) on activity of 5-fluorouracil (FUra) and folinic acid (FA)-containing regimens was studied in 50 patients including 14 with digestive tract, and 36 with breast carcinomas (BC) in advanced stages with poor prognostic characteristics. Patients with colorectal, and pancreas adenocarcinoma received oxaliplatin, irinotecan, FUra, FA (Folfirinox), and patients with squamous cell carcinoma of the esophagus had paclitaxel, carboplatin, FUra, FA (TCbF). Patients with BC received AVCF (doxorubicin, vinorelbine, cyclophosphamide, FUra, FA) followed by TCbF or TCbF only, and patients who overexpressed HER2 received TCbF plus trastuzumab and pertuzumab. PN (1000-3000 mg/day iv) preceded each administration of FUra and FA. 47 patients (94%) responded, including 16 (32%) with CR. Median tumor reduction was 93%. Median event-free survival (EFS) was 37.7 months. The 25 patients with tumor shrinkage ≥ 91% had EFS of 52% from 42 months onwards. Unexpected toxicity did not occur. PN enhances potency of chemotherapy regimens comprising FUra and FA.
Collapse
Affiliation(s)
- David Machover
- INSERM U935-UA09, University Paris-Saclay, Paul-Brousse Hospital, 12, Avenue Paul-Vaillant-Couturier, 94800, Villejuif, France.
| | - Wathek Almohamad
- Department of Medical Oncology, University Paris-Saclay, Paul-Brousse Hospital, Assistance Publique-Hôpitaux de Paris (APHP), 94800, Villejuif, France
| | - Vincent Castagné
- Department of Pharmacy, University Paris-Saclay, Paul-Brousse Hospital, APHP, 94800, Villejuif, France
| | - Christophe Desterke
- INSERM U935-UA09, University Paris-Saclay, Paul-Brousse Hospital, 12, Avenue Paul-Vaillant-Couturier, 94800, Villejuif, France
| | - Léa Gomez
- Department of Biophysics and Nuclear Medicine, University Paris-Saclay, Kremlin-Bicêtre Hospital, APHP, 94270, Le Kremlin-Bicêtre, France
| | - Emma Goldschmidt
- Department of Medical Oncology, University Paris-Saclay, Paul-Brousse Hospital, Assistance Publique-Hôpitaux de Paris (APHP), 94800, Villejuif, France
| |
Collapse
|
2
|
A phase I/II study of arfolitixorin and 5-fluorouracil in combination with oxaliplatin (plus or minus bevacizumab) or irinotecan in metastatic colorectal cancer. ESMO Open 2022; 7:100589. [PMID: 36183444 PMCID: PMC9588906 DOI: 10.1016/j.esmoop.2022.100589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/18/2022] [Accepted: 08/21/2022] [Indexed: 11/21/2022] Open
Abstract
Background 5-fluorouracil (5-FU) combined with a folate remains an essential treatment component for metastatic colorectal cancer (mCRC). Leucovorin is the folate most often used, but requires intracellular conversion to a reduced folate, and has high pharmacokinetic variability and limited bioavailability in patients with low folate pathway gene expression. Arfolitixorin is an immediately active form of folate, [6R]-5,10-methylenetetrahydrofolate ([6R]-MTHF), and may improve outcomes. Patients and methods This open-label, multicenter, phase I/II study in patients with mCRC (NCT02244632) assessed the tolerability and efficacy of first- or second-line arfolitixorin (30, 60, 120, or 240 mg/m2 intravenous) with 5-FU alone, or in combination with oxaliplatin (plus or minus bevacizumab) or irinotecan, every 14 days. Safety, efficacy, and pharmacokinetics were assessed before and after four cycles (8 weeks) of treatment. Results In 105 treated patients, investigators reported 583 adverse events (AEs) in 86 patients (81.9%), and 256 AEs (43.9%) were potentially related to arfolitixorin and 5-FU. Dose adjustments were required in 16 patients (15.2%). At 8 weeks, 9 out of 57 patients assessed for efficacy achieved an objective response (15.8%), and all 9 achieved a partial response. Six of these nine patients had received arfolitixorin as a first-line treatment. A further 33 patients (57.9%) achieved stable disease. Pharmacokinetics were assessed in 35 patients. The average tmax was 10 min, and area under the plasma concentration–time curve from time 0 to 1 h increased linearly between 30 and 240 mg/m2. No accumulation was observed for [6R]-MTHF following repeated administration, and there were no major pharmacokinetic differences between cycle 1 and cycle 4 at any dose. Conclusions Arfolitixorin is a well-tolerated moderator of 5-FU activity. It is suitable for further investigation in mCRC and has the potential to improve treatment outcomes in patients with low folate pathway gene expression. Arfolitixorin can easily be incorporated into current standard of care, requiring minimal changes to chemotherapy regimens. Arfolitixorin is an immediately active form of folate and may improve outcomes with 5-FU-based chemotherapy. This phase I/II clinical trial demonstrated that arfolitixorin is a well-tolerated and effective folate agent in mCRC. Arfolitixorin can easily be incorporated into the current standard of care and is suitable for further investigation.
Collapse
|
3
|
Machover D, Goldschmidt E, Almohamad W, Castagné V, Dairou J, Desterke C, Gomez L, Gaston-Mathé Y, Boucheix C. Pharmacologic modulation of 5-fluorouracil by folinic acid and pyridoxine for treatment of patients with advanced breast carcinoma. Sci Rep 2022; 12:9079. [PMID: 35641554 PMCID: PMC9156777 DOI: 10.1038/s41598-022-12998-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 05/12/2022] [Indexed: 11/24/2022] Open
Abstract
High concentration pyridoxal 5’-phosphate, the cofactor of vitamin B6, potentiates cytotoxicity in cancer cells exposed to 5-fluorouracil (FUra) and folinic acid (FA). We studied the effect of high-dose pyridoxine on antitumor activity of regimens comprising FUra and FA in 27 advanced breast carcinoma patients. Of 18 previously untreated patients, 12 had tumors that did not overexpress HER2 (Group I), and 6 that overexpressed HER2 (Group II). Nine patients (Group III) had prior chemotherapy. Group I received AVCF (doxorubicin, vinorelbine, cyclophosphamide, FUra, FA) or FAC (doxorubicin, cyclophosphamide, FUra, FA) followed by TCbF (paclitaxel carboplatin, FUra, FA). Groups II, and III received TCbF. Pyridoxine iv (1000–3000 mg/day) preceded each FA and FUra. Group II also received trastuzumab and pertuzumab. 26 patients responded. Three patients in Group I had CRs and 9 had PRs with 62–98% reduction rates; 4 patients in Group II had CRs and 2 had PRs with 98% reduction. Of 7 measurable patients in Group III, 2 attained CRs, and 5 had PRs with 81–94% reduction rates. Median time to response was 3.4 months. Unexpected toxicity did not occur. This pilot study suggests that high-dose vitamin B6 enhances antitumor potency of regimens comprising FUra and FA.
Collapse
Affiliation(s)
- David Machover
- INSERM U935-UA09 and Institut de Cancérologie et d'Immunogénétique (ICIG), Paul-Brousse Hospital, University Paris-Saclay, 12, Avenue Paul-Vaillant-Couturier, 94800, Villejuif, France.
| | - Emma Goldschmidt
- Department of Medical Oncology, Paul-Brousse Hospital, Assistance Publique-Hôpitaux de Paris (APHP), University Paris-Saclay, 94800, Villejuif, France
| | - Wathek Almohamad
- Department of Medical Oncology, Paul-Brousse Hospital, Assistance Publique-Hôpitaux de Paris (APHP), University Paris-Saclay, 94800, Villejuif, France
| | - Vincent Castagné
- Department of Pharmacy, Paul-Brousse Hospital, APHP, University Paris-Saclay, 94800, Villejuif, France
| | - Julien Dairou
- Laboratory of Pharmacologic Biochemistry and Toxicology, CNRS UMR 8601, University Paris-Descartes, 45, Rue des Saints-Pères, 75006, Paris, France
| | - Christophe Desterke
- INSERM U935-UA09 and Institut de Cancérologie et d'Immunogénétique (ICIG), Paul-Brousse Hospital, University Paris-Saclay, 12, Avenue Paul-Vaillant-Couturier, 94800, Villejuif, France
| | - Léa Gomez
- Department of Biophysics and Nuclear Medicine, Kremlin-Bicêtre Hospital, APHP, University Paris-Saclay, 94270, Le Kremlin-Bicêtre, France
| | | | - Claude Boucheix
- INSERM U935-UA09 and Institut de Cancérologie et d'Immunogénétique (ICIG), Paul-Brousse Hospital, University Paris-Saclay, 12, Avenue Paul-Vaillant-Couturier, 94800, Villejuif, France
| |
Collapse
|
4
|
Glimelius B, Stintzing S, Marshall J, Yoshino T, de Gramont A. Metastatic colorectal cancer: Advances in the folate-fluoropyrimidine chemotherapy backbone. Cancer Treat Rev 2021; 98:102218. [PMID: 34015686 DOI: 10.1016/j.ctrv.2021.102218] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 12/22/2022]
Abstract
Notwithstanding recent treatment advances in metastatic colorectal cancer (mCRC), chemotherapy with a combination of a fluoropyrimidine and a folate agent, often 5-fluorouracil (5-FU) and leucovorin, remains the backbone of treatment regimens for the majority of patients with mCRC. This is despite a recent focus on molecular-targeted treatments and patient stratification according to mutational status or expression levels of specific genes. Intracellular folate concentration was discovered to be pivotal in the cytotoxic efficacy of 5-FU, paving the way to the current standard combination therapy approach. Subsequent discovery that systemic chemotherapy agents, such as irinotecan and oxaliplatin, can further increase the efficacy of 5-FU-based treatments led to the development of several combination chemotherapy regimens, including FOLFOX, FOLFIRI and FOLFOXIRI. Subsequent efforts to optimise 5-FU-based treatments have focused on 5-FU analogues, initially capecitabine and the combination drug tegafur/gimeracil/oteracil (S-1) and then TAS-102, which has recently been evaluated in phase 3 clinical trials for refractory colorectal cancer. Further approaches taken to improve the efficacy of 5-FU chemotherapy regimens have focused on optimising the route and dosing schedules and regulating folate metabolism. Pharmacokinetic variability caused by the requirement for metabolic conversion of leucovorin has been central to recent research, and the development of agents such as arfolitixorin which bypass the need for metabolic conversion remains promising for future therapeutic candidates. In this review, we summarise the evidence leading to the current treatment regimens employing 5-FU and leucovorin, focusing on recent approaches taken to optimise and refine treatments to improve clinical outcomes in patients with mCRC.
Collapse
Affiliation(s)
- Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
| | - Sebastian Stintzing
- Department of Hematology, Oncology, and Tumor Immunology (CCM) Charité, University Medicine Berlin, Berlin, Germany
| | - John Marshall
- Georgetown University Medical Center, Washington, DC, USA
| | | | | |
Collapse
|
5
|
Taflin H, Odin E, Carlsson G, Tell R, Gustavsson B, Wettergren Y. Plasma deoxyuridine as a surrogate marker for toxicity and early clinical response in patients with metastatic colorectal cancer after 5-FU-based therapy in combination with arfolitixorin. Cancer Chemother Pharmacol 2020; 87:31-41. [PMID: 33099678 PMCID: PMC7801297 DOI: 10.1007/s00280-020-04173-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/06/2020] [Indexed: 12/24/2022]
Abstract
Purpose The aim was to explore the correlation between increasing doses of [6R]-5,10-methylenetetrahydrofolate (arfolitixorin) and plasma concentrations of deoxyuridine (dUr) in patients with metastatic colorectal cancer (mCRC), subjected to 5-fluorouracil (5-FU)-based chemotherapy. The aim was further to investigate the possibility to predict toxicity and clinical response during treatment using gender, age, and plasma dUr as explanatory variables. Methods Thirty-three patients from the ISO-CC-005 phase I/IIa study, which investigated safety and tolerability of arfolitixorin at four dose levels, were included. Toxicity and clinical response were evaluated after 4 cycles of chemotherapy. Plasma dUr was quantified before (0 h) and 24 h after 5-FU administration at the first (C1) and fourth (C4) cycle using LC–MS/MS. Fit modelling was used to predict toxicity and clinical response. Results The dUr levels increased with increasing arfolitixorin dose. Females had higher total and haematological toxicity scores (p = 0.0004 and 0.0089, respectively), and needed dose reduction more often than males (p = 0.012). Fit modeling showed that gender and the dUr levels at C1-0 h and C4-24 h predicted total toxicity (p = 0.0011), whereas dUr C4-0 h alone was associated with gastrointestinal toxicity (p = 0.026). Haematological toxicity was predicted by gender and age (p = 0.0071). The haematological toxicity score in combination with the dUr levels at C1-24 h and C4-24 h predicted early clinical response (p = 0.018). Conclusion The dUr level before and during administration of 5-FU and arfolitixorin was predictive for toxicity and early clinical response and could be a potential surrogate marker for thymidylate synthase inhibition in patients with mCRC. Trial registration NCT02244632, first posted on ClinicalTrials.gov on September 19, 2014 Electronic supplementary material The online version of this article (10.1007/s00280-020-04173-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Helena Taflin
- Department of Surgery, The Institute of Clinical Sciences, The Sahlgrenska Academy At University of Gothenburg, Göteborg, Sweden
| | - Elisabeth Odin
- Department of Surgery, The Institute of Clinical Sciences, The Sahlgrenska Academy At University of Gothenburg, Göteborg, Sweden
| | - Göran Carlsson
- Department of Surgery, The Institute of Clinical Sciences, The Sahlgrenska Academy At University of Gothenburg, Göteborg, Sweden
| | | | - Bengt Gustavsson
- Department of Surgery, The Institute of Clinical Sciences, The Sahlgrenska Academy At University of Gothenburg, Göteborg, Sweden
| | - Yvonne Wettergren
- Department of Surgery, The Institute of Clinical Sciences, The Sahlgrenska Academy At University of Gothenburg, Göteborg, Sweden.
| |
Collapse
|
6
|
Odin E, Sondén A, Carlsson G, Gustavsson B, Wettergren Y. Folate pathway genes linked to mitochondrial biogenesis and respiration are associated with outcome of patients with stage III colorectal cancer. Tumour Biol 2019; 41:1010428319846231. [PMID: 31223065 DOI: 10.1177/1010428319846231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
5-fluorouracil in combination with the folate leucovorin is the cornerstone in treatment of colorectal cancer. Transport of leucovorin into cells, and subsequent metabolic action, require expression of several genes. The aim was to analyze if tumoral expression of genes putatively involved in leucovorin transport, polyglutamation, or metabolism was associated with outcome of patients with stage III colorectal cancer treated with adjuvant chemotherapy. A total of 363 stage III colorectal cancer patients who received adjuvant bolus 5-fluorouracil + leucovorin alone, or in combination with oxaliplatin according to Nordic bolus regimes were included. Expression of 11 folate pathway genes was determined in tumors using quantitative real-time polymerase chain reaction and related to disease-free survival. The median follow-up time was 5 years. During follow-up, 114 (31%) patients suffered from recurrent disease. A high tumoral expression of the genes SLC46A1/PCFT, SLC19A1/RFC-1, ABCC3/MRP3, GGH, and MTHFD1L, which are involved in folate transport, polyglutamation, or metabolism, was associated with longer disease-free survival of the patients. Each of these genes either encodes mitochondrial enzymes or is being regulated by mitochondrial transcription factors. Expression of the SLC46A1/PCFT gene was most strongly associated with disease-free survival, regardless of treatment regimen. In conclusion, the results show that expression of folate pathway genes are associated with outcome of colorectal cancer patients treated with adjuvant 5-fluorouracil in combination with leucovorin. A prospective study needs to be conducted to determine if expression of these genes can be used to predict response to leucovorin and other folates that are now being tested in clinical studies. Moreover, there seems to be a link between folate metabolism and mitochondrial biogenesis and respiration that deserves further exploration.
Collapse
Affiliation(s)
- Elisabeth Odin
- 1 Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Arvid Sondén
- 2 Bioinformatics Core Facilities, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Carlsson
- 1 Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bengt Gustavsson
- 1 Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Yvonne Wettergren
- 1 Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
7
|
Folates as adjuvants to anticancer agents: Chemical rationale and mechanism of action. Crit Rev Oncol Hematol 2016; 106:118-31. [PMID: 27637357 DOI: 10.1016/j.critrevonc.2016.08.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 07/01/2016] [Accepted: 08/09/2016] [Indexed: 12/31/2022] Open
|
8
|
Gustavsson B, Carlsson G, Swartling T, Kurlberg G, Derwinger K, Björkqvist H, Odin E, Gibson F. Phase 1 dose de-escalation trial of the endogenous folate [6R]-5,10-methylene tetrahydrofolate in combination with fixed-dose pemetrexed as neoadjuvant therapy in patients with resectable rectal cancer. Invest New Drugs 2015; 33:1078-85. [PMID: 26189513 PMCID: PMC4768212 DOI: 10.1007/s10637-015-0272-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 07/07/2015] [Indexed: 01/04/2023]
Abstract
Background Modufolin® ([6R]-5,10-methylene tetrahydrofolate; [6R]-MTHF) is an endogenous biomodulator that is being developed as an alternative to leucovorin, a folate prodrug used in the treatment of colorectal cancer. The objective of this phase 1 dose de-escalation trial was to estimate the minimum tolerated dose of [6R]-MTHF to be used in combination with pemetrexed 500 mg/m2 in the neoadjuvant treatment of patients with rectal cancer. Methods Adult patients (≥18 years) with resectable rectal adenocarcinoma were allocated to [6R]-MTHF doses of 500, 100, 50, and 10 mg/m2 in combination with pemetrexed 500 mg/m2. [6R]-MTHF was administered as an intravenous (i.v.) bolus injection 1 week prior to the first dose of pemetrexed and then once weekly for 9 weeks; pemetrexed was administered by i.v. infusion once every 21 days for three cycles. Results Twenty-four patients (mean [SD] age, 63.1 [12.9] years) were enrolled in the study. A total of 72 treatment-related adverse events (AEs) were reported, of which the most common were fatigue (n = 17; 23.6 %), nausea (n = 10; 13.9 %), and diarrhea (n = 5; 6.9 %). The incidence of treatment-related AEs by [6R]-MTHF dose level (500, 100, 50, 10 mg/m2) was 11.1 % (n = 8), 13.9 % (n = 10), 45.8 % (n = 33), and 29.2 % (n = 21), respectively. There were no dose-limiting toxicities, and only two (2.8 %) treatment-related AEs were grade 3 in severity. Of the 11 serious AEs reported, none were considered to be related to [6R]-MTHF treatment. Conclusions The results of this phase 1 study indicate that the estimated minimum tolerated dose of [6R]-MTHF was 100 mg/m2 once weekly in combination with pemetrexed 500 mg/m2. The low toxicity profile of [6R]-MTHF supports its further evaluation as a component of systemic chemotherapy in the management of colon and rectal cancer.
Collapse
Affiliation(s)
- Bengt Gustavsson
- Department of Surgery, University of Gothenburg, Sahlgrenska University Hospital/Östra Institute of Clinical Sciences, Gothenburg, Sweden
| | - Göran Carlsson
- Department of Surgery, University of Gothenburg, Sahlgrenska University Hospital/Östra Institute of Clinical Sciences, Gothenburg, Sweden
| | - Torbjörn Swartling
- Department of Surgery, University of Gothenburg, Sahlgrenska University Hospital/Östra Institute of Clinical Sciences, Gothenburg, Sweden
| | - Göran Kurlberg
- Department of Surgery, University of Gothenburg, Sahlgrenska University Hospital/Östra Institute of Clinical Sciences, Gothenburg, Sweden
| | - Kristoffer Derwinger
- Department of Surgery, University of Gothenburg, Sahlgrenska University Hospital/Östra Institute of Clinical Sciences, Gothenburg, Sweden
| | - Hillevi Björkqvist
- Department of Surgery, University of Gothenburg, Sahlgrenska University Hospital/Östra Institute of Clinical Sciences, Gothenburg, Sweden
| | - Elisabeth Odin
- Department of Surgery, University of Gothenburg, Sahlgrenska University Hospital/Östra Institute of Clinical Sciences, Gothenburg, Sweden
| | - Fernando Gibson
- PharmaGenesis London, 9 Whitehall, 4th Floor, London, SW1A 2DD, UK.
| |
Collapse
|