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D'Adamo DR, Dickson MA, Keohan ML, Carvajal RD, Hensley ML, Hirst CM, Ezeoke MO, Ahn L, Qin LX, Antonescu CR, Lefkowitz RA, Maki RG, Schwartz GK, Tap WD. A Phase II Trial of Sorafenib and Dacarbazine for Leiomyosarcoma, Synovial Sarcoma, and Malignant Peripheral Nerve Sheath Tumors. Oncologist 2019; 24:857-863. [PMID: 30126857 PMCID: PMC6656505 DOI: 10.1634/theoncologist.2018-0160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/31/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Sorafenib and dacarbazine have low single-agent response rates in metastatic sarcomas. As angiogenesis inhibitors can enhance the efficacy of chemotherapy, we investigated the combination of sorafenib and dacarbazine in select sarcoma subtypes. MATERIALS AND METHODS Patients with leiomyosarcoma (LMS), synovial sarcoma (SS), or malignant peripheral nerve sheath tumors (MPNST) with up to two previous lines of therapy and adequate hepatic, renal, and marrow function received 3-week cycles of sorafenib at 400 mg oral twice daily and dacarbazine 1,000 mg/m2 intravenously (later reduced to 850 mg/m2). Patients were evaluated for response every 6 weeks. The primary objective was to determine the disease control rate (DCR) of sorafenib plus dacarbazine in the selected sarcoma subtypes. RESULTS The study included 37 patients (19 female); median age was 55 years (range 26-87); and histologies included LMS (22), SS (11), and MPNST (4). The DCR was 46% (17/37). Median progression-free survival was 13.4 weeks. The RECIST response rate was 14% (5/37). The Choi response rate was 51% (19/37). Median overall survival was 13.2 months. Of the first 25 patients, 15 (60%) required dacarbazine dose reductions for hematologic toxicity, with one episode of grade 5 neutropenic fever. After reducing the starting dose of dacarbazine to 850 mg/m2, only 3 of the final 12 (25%) patients required dose reduction. CONCLUSION This phase II study met its primary endpoint with an 18-week DCR of 46%. The clinical activity of dacarbazine plus sorafenib in patients with these diagnoses is modest. IMPLICATIONS FOR PRACTICE Metastatic soft tissue sarcomas are a heterogeneous group of relatively rare malignancies. Most patients are treated with cytotoxic chemotherapy or targeted therapy in the form of tyrosine kinase inhibitors. Response rates are relatively low, and there is a need for better therapies. This clinical trial demonstrates that combining a cytotoxic therapy (dacarbazine) with an antiangiogenic small molecule (sorafenib) is feasible and associated with favorable disease-control rates; however, it also increases the potential for significant toxicity.
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Affiliation(s)
| | - Mark A Dickson
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Mary L Keohan
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | | | - Martee L Hensley
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Catherine M Hirst
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Marietta O Ezeoke
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Linda Ahn
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Li-Xuan Qin
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Cristina R Antonescu
- Department of Pathology, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Robert A Lefkowitz
- Department of Radiology, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | | | - Gary K Schwartz
- Department of Medicine, Columbia University, New York, New York, USA
| | - William D Tap
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
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Sleijfer S, Judson I, Demetri GD. How to decide whether to offer and use "nonstandard" therapies in patients with advanced sarcomas and gastrointestinal stromal tumors: global variations in clinical practice, assessment, and access to therapies in diseases with limited incidence and data. Am Soc Clin Oncol Educ Book 2016:645-50. [PMID: 24451812 DOI: 10.14694/edbook_am.2012.32.304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
As cancer is more generally recognized as a collection of various rare diseases rather than a homogeneous illness, sarcomas have become a model for the manner in which data can and cannot be used to drive clinical decision making. In this article, we explore the limitations of data generated in rare diseases such as sarcomas to provide an evidence base for clinical practice. How should patients be treated if there is no "standard" that offers "proof" of clinical benefit? By asking this question, we also raise the issue of what constitutes "clinical benefit"-and how to measure that-for patients with sarcomas and other rare diseases. As physicians become more accountable for decisions-and yet are always accountable to the patients and families who rely on them to provide the best and most appropriate care-oncologists must be cognizant of the limitations of data in rare diseases and be ready to justify actions that are in the best medical and social interests of patients.
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Affiliation(s)
- Stefan Sleijfer
- From the Erasmus MC Daniel Den Hoed Cancer Center, Rotterdam, Netherlands; CR UK Centre for Cancer Therapeutics, Sutton, United Kingdom; Ludwig Center and Sarcoma Center, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Ian Judson
- From the Erasmus MC Daniel Den Hoed Cancer Center, Rotterdam, Netherlands; CR UK Centre for Cancer Therapeutics, Sutton, United Kingdom; Ludwig Center and Sarcoma Center, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - George D Demetri
- From the Erasmus MC Daniel Den Hoed Cancer Center, Rotterdam, Netherlands; CR UK Centre for Cancer Therapeutics, Sutton, United Kingdom; Ludwig Center and Sarcoma Center, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
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Bauer S, Joensuu H. Emerging Agents for the Treatment of Advanced, Imatinib-Resistant Gastrointestinal Stromal Tumors: Current Status and Future Directions. Drugs 2015; 75:1323-34. [PMID: 26187774 PMCID: PMC4532715 DOI: 10.1007/s40265-015-0440-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Imatinib is strongly positioned as the recommended first-line agent for most patients with advanced gastrointestinal stromal tumor (GIST) due to its good efficacy and tolerability. Imatinib-resistant advanced GIST continues to pose a therapeutic challenge, likely due to the frequent presence of multiple mutations that confer drug resistance. Sunitinib and regorafenib are approved as second- and third-line agents, respectively, for patients whose GIST does not respond to imatinib or who do not tolerate imatinib, and their use is supported by large randomized trials. ATP-mimetic tyrosine kinase inhibitors provide clinical benefit even in heavily pretreated GIST suggesting that oncogenic dependency on KIT frequently persists. Several potentially useful tyrosine kinase inhibitors with distinct inhibitory profiles against both KIT ATP-binding domain and activation loop mutations have not yet been fully evaluated. Agents that have been found promising in preclinical models and early clinical trials include small molecule KIT and PDGFRA mutation-specific inhibitors, heat shock protein inhibitors, histone deacetylase inhibitors, allosteric KIT inhibitors, KIT and PDGFRA signaling pathway inhibitors, and immunological approaches including antibody-drug conjugates. Concomitant or sequential administration of tyrosine kinase inhibitors with KIT signaling pathway inhibitors require further evaluation, as well as rotation of tyrosine kinase inhibitors as a means to suppress drug-resistant cell clones.
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Affiliation(s)
- Sebastian Bauer
- />Sarcoma Center, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- />German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Heikki Joensuu
- />Department of Oncology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00029 Helsinki, Finland
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Kee D, Zalcberg JR. Current and emerging strategies for the management of imatinib-refractory advanced gastrointestinal stromal tumors. Ther Adv Med Oncol 2012; 4:255-70. [PMID: 22942908 DOI: 10.1177/1758834012450935] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Since its approval by the US Food and Drug Administration in February 2002, the tyrosine kinase inhibitor, imatinib, has become the standard of care for patients with metastatic or unresectable KIT-positive gastrointestinal stromal tumors (GISTs). Imatinib functions by blocking the adenosine triphosphate binding site of the constitutively activated mutant KIT or platelet-derived growth factor receptor α, effectively shutting down the oncogenic signal that drives up to 90% of these tumors. In doing so, it has transformed the management of a condition previously refractory to systemic treatments and established GIST as a model for the use of targeted therapies and oncogene addiction in solid tumors. However, while more than 80% of patients will receive clinical benefit from imatinib monotherapy, more than half will develop progressive disease by 2 years. In this article we review the mechanism and patterns of imatinib resistance in GIST; attempt to offer a practical schema for managing imatinib-refractory patients; and lastly, offer some insight as to future directions and emerging therapeutics for the management of this highly interesting and challenging disease.
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Affiliation(s)
- Damien Kee
- Department of Cancer Medicine, Peter MacCallum Cancer Centre, St Andrews Place, East Melbourne, VIC 3002 and Department of Pathology, University of Melbourne, Parkville, VIC, Australia
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Kim EJ, Zalupski MM. Systemic therapy for advanced gastrointestinal stromal tumors: beyond imatinib. J Surg Oncol 2011; 104:901-6. [PMID: 22069175 DOI: 10.1002/jso.21872] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Progression on first-line therapy with imatinib in gastrointestinal stromal tumors (GIST) is caused by either initial resistance or more often a secondary mutation in tyrosine kinases KIT or PDGFR. Therapies in development for imatinib-resistant GIST include agents that target KIT/PDGFR with greater potency or possess broader kinase inhibition profiles including VEGFR. To circumvent secondary mutations in KIT/PDGFR, inhibition of the downstream signaling in PI3K/Akt/mTOR pathway and enhanced degradation of KIT/PDGFR are also under investigation.
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Affiliation(s)
- Edward J Kim
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan 48109-5934, USA
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[Systemic therapy of soft tissue sarcomas]. DER PATHOLOGE 2010; 32:65-71. [PMID: 21053001 DOI: 10.1007/s00292-010-1397-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The gold standard for the treatment of primary, resectable, high-grade soft tissue sarcomas is complete surgical removal followed by radiotherapy. In cases where preservation of function is not possible, preoperative treatment options should be considered. Systemic therapy is the treatment of choice for metastatic soft tissue sarcomas. The most active single agents include the anthracyclines doxorubicin and epirubicin, as well as ifosfamide. While combination chemotherapy yields higher response rates, this is at the cost of increased toxicity with no evidence of prolonged overall survival. Current treatment strategies focus on the development of specific treatments for well defined soft tissue sarcoma subtypes. The first and highly successful targeted therapy was seen with the introduction of imatinib in the treatment of gastrointestinal stromal tumors.
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Molecular response prediction in gastrointestinal stromal tumors. Target Oncol 2010; 5:29-37. [DOI: 10.1007/s11523-010-0134-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 03/12/2010] [Indexed: 11/26/2022]
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Pacey S, Ratain MJ, Flaherty KT, Kaye SB, Cupit L, Rowinsky EK, Xia C, O'Dwyer PJ, Judson IR. Efficacy and safety of sorafenib in a subset of patients with advanced soft tissue sarcoma from a Phase II randomized discontinuation trial. Invest New Drugs 2009; 29:481-8. [PMID: 20016927 DOI: 10.1007/s10637-009-9367-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 11/26/2009] [Indexed: 01/19/2023]
Abstract
AIM Phase II multi-disease randomized discontinuation trial to assess the safety and efficacy of sorafenib including patients with advanced soft tissue sarcoma (STS). METHODS Sorafenib (400 mg twice daily) was initially administered for 12 weeks. Patients with: ≥25% tumour shrinkage continued sorafenib; ≥25% tumour growth discontinued; other patients were randomized and received sorafenib or placebo. RESULTS Twenty-six patients (median age 55 years) were enrolled. Common drug-related adverse events, including fatigue, hand-foot skin reaction, rash or gastrointestinal disturbances, were manageable, reversible and generally low grade. Fatigue, skin toxicity, nausea, diarrhoea and hypertension occurred at grade ≥3 in 19% of patients. After 12 weeks eight (31%) patients had not progressed. Three patients who experienced tumour shrinkage and continued on sorafenib, and five (19%) were randomized either to continue sorafenib or to receive placebo. Of the three patients randomized to sorafenib, one achieved a partial response and two had SD. Overall one patient achieved a partial response and three further patients achieved minor responses. CONCLUSIONS There was evidence of disease activity in STS as defined by tumor regressions including one objective partial response. Further investigation in STS is warranted.
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Affiliation(s)
- Simon Pacey
- The Royal Marsden Hospital, Downs Rd, Sutton, Surrey, SM2 5PT, UK
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Gramza AW, Corless CL, Heinrich MC. Resistance to Tyrosine Kinase Inhibitors in Gastrointestinal Stromal Tumors. Clin Cancer Res 2009; 15:7510-7518. [PMID: 20008851 DOI: 10.1158/1078-0432.ccr-09-0190] [Citation(s) in RCA: 165] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Gastrointestinal stromal tumors (GIST) are the most common type of sarcoma in the gastrointestinal tract. Surgery is the primary treatment modality, but many patients suffer disease recurrence or metastasis. Fortunately, the management of advanced GIST has been revolutionized by the use of small molecule kinase inhibitors that target the underlying pathogenetic mutant kinases found in the vast majority of cases. Approximately 85% of GISTs have oncogenic mutations in KIT, allowing for constitutive kinase activation that is responsible for cellular proliferation and survival. About 5 to 7% of GISTs have activating mutations of the homologous platelet-derived growth factor receptor alpha (PDGFRA) kinase. The progression-free and overall survival of patients with advanced disease is greatly improved by treatment with the kinase inhibitors imatinib and sunitinib. However, the emergence of drug-resistant tumor clones limits the long-term benefit of these drugs in most patients. Resistance to these kinase inhibitors is associated with distinctive clinical and molecular features, with the development of secondary mutations of the oncogenic kinase being the most common mechanism. We review the molecular basis of GIST response and/or resistance to TKIs, and discuss strategies to prevent and/or overcome drug resistance. These concepts are directly relevant to the development of targeted molecular therapy for other solid tumors. (Clin Cancer Res 2009;15(24):7510-8).
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Affiliation(s)
- Ann W Gramza
- Authors' Affiliations: Portland VA Medical Center and Oregon Health and Science University Knight Cancer Institute, Portland, Oregon
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Combined treatment strategies in gastrointestinal stromal tumors (GISTs) after imatinib and sunitinib therapy. Cancer Treat Rev 2009; 36:63-8. [PMID: 19914780 DOI: 10.1016/j.ctrv.2009.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 10/14/2009] [Accepted: 10/19/2009] [Indexed: 12/14/2022]
Abstract
Resistance to tyrosine-kinase inhibitors remains an open issue in the treatment of patients with gastrointestinal stromal tumors. The complex biology of disease in the multi-resistant setting has led a progressively growing urgency and interest in development combined or integrated therapies. This mini-review outlines the rationale for developing new combined therapeutic approaches, and describes the state of the art of the various potential strategies and the promising research perspectives.
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Reichardt P. [Internal medical therapy of gastrointestinal stroma tumors]. Radiologe 2009; 49:1128-31. [PMID: 19701624 DOI: 10.1007/s00117-009-1854-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Until recently no active treatment for advanced or metastatic gastrointestinal stroma tumors (GIST) was available. The tyrosine kinase inhibitor imatinib has revolutionized the treatment of this disease and the median overall survival now reaches 5 years. The standard dose of imatinib is 400 mg per day. Locally advanced GIST should be treated with systemic therapy prior to surgical resection. Imatinib was recently licensed for adjuvant therapy following complete surgical removal of GIST in patients with a significant risk of recurrence.
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Affiliation(s)
- P Reichardt
- Klinik für Innere Medizin III, Sarkomzentrum Berlin-Brandenburg, HELIOS Klinikum Bad Saarow, Pieskower Strasse 33, Bad Saarow, Germany.
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