A Phase II Study of Pazopanib in Patients with Malignant Pleural Mesothelioma: NCCTG N0623 (Alliance)

Short Report of a Phase II Trial of Nintedanib in Recurrent Malignant Pleural Mesothelioma (MPM)

Background:

Malignant pleural mesothelioma (MPM) is a disease for which there remains an unmet need for better therapeutic options. Nintedanib is an oral multikinase inhibitor impacting VEGF, FGF, PDGFR, and other kinase activity such as TGFß signaling pathways. We conducted a phase II trial of nintedanib in patients with recurrent MPM.

Methods:

Patients with MPM previously treated with platinum-based chemotherapy, performance status (PS) 0–1, adequate organ function, and no contraindications to anti-angiogenic therapy were eligible and were treated with nintedanib 200 mg twice per day until disease progression or unacceptable toxicity. The primary endpoint was 4-month progression-free survival (PFS).

Results:

Twenty patients were enrolled. The median age was 70 years (range 32–81), 90% were male, and 80% were PS 1. The histology was 70% epithelioid, 5% sarcomatoid, 10% biphasic, and 15% unknown. 15% had prior bevacizumab. The median follow-up was 4.1 mo. There were no responses but 40% had stable disease at 8 weeks. The median PFS was 1.8 mo. (95% CI: 1.68, 3.55) and the 4-month PFS rate was 13%. The median OS was 4.2 mo. (95% CI: 2.53, 8.74) and the 4-month OS rate was 55%. Toxicities were primarily grade 1–2 and included diarrhea, fatigue, edema, transaminase elevation, anorexia, nausea, vomiting and dyspnea.

Conclusions:

The activity of nintedanib in previously treated MPM patients was. modest. The trial did not meet its primary PFS endpoint. Even though 2 patients had prolonged stable disease for >4 months, the efficacy of nintedanib remains unproven.

This is a Phase II trial assessing the efficacy of nintedanib, an oral multi-targeted kinase inhibitor, in patients with recurrent malignant pleural mesothelioma. The drug was well tolerated but the activity was modest with no responses and 40% stable disease at 8 weeks. The trial did not meet its endpoint but there was a subset of patients who had prolonged stable disease.

Current Management and Future Perspective in Pleural Mesothelioma

Pleural mesothelioma is an aggressive malignancy arising from pleural mesothelial cell lining, predominantly associated with prior exposure to asbestos. The ban on asbestos use has led to its lower incidence in many countries, but globally the disease burden is expected to rise. Therefore, well-planned research is needed to develop more effective, tolerable and affordable drugs. The development of novel treatment has been too slow, with only two regimens of systemic therapy with robust phase 3 data approved formally to date. The treatment scenario for resectable disease remains controversial. However, recent developments in the understanding of disease and clinical trials have been encouraging, and may add better treatment options in the coming years. In this review, we discuss the current treatment options for pleural mesothelioma and shed light on some recent studies and ongoing trials.

Novel and Promising Systemic Treatment Approaches in Mesothelioma

OPINION STATEMENT

There was limited progress in the development of novel systemic approaches in the treatment of advanced malignant mesothelioma for years following the publication of the pivotal phase III trial of Vogelzang et al. that established the cisplatin/pemetrexed regimen as a standard 1st-line systemic therapy. Since then, over the last several years, a significant step forward has been made, with incorporation of immune checkpoint inhibitors and anti-angiogenic agents. In addition, better appreciation of mesothelioma biology has allowed detection of novelmolecular therapeutic targets. All the above-mentioned strategies, along with the additional promising approaches represented by adoptive T cell therapy, dendritic cell therapy, cancer vaccines, oncoviral therapy, and agents targeting mesothelin are discussed in this review. The clinical research to identify effective biologic targets and treatment combinations in malignant mesothelioma is ongoing.