Myelopreservation with the CDK4/6 inhibitor trilaciclib in patients with small-cell lung cancer receiving first-line chemotherapy: a phase Ib/randomized phase II trial

BACKGROUND

Chemotherapy-induced damage of hematopoietic stem and progenitor cells (HSPC) causes multi-lineage myelosuppression. Trilaciclib is an intravenous CDK4/6 inhibitor in development to proactively preserve HSPC and immune system function during chemotherapy (myelopreservation). Preclinically, trilaciclib transiently maintains HSPC in G1 arrest and protects them from chemotherapy damage, leading to faster hematopoietic recovery and enhanced antitumor immunity.

PATIENTS AND METHODS

This was a phase Ib (open-label, dose-finding) and phase II (randomized, double-blind placebo-controlled) study of the safety, efficacy and PK of trilaciclib in combination with etoposide/carboplatin (E/P) therapy for treatment-naive extensive-stage small-cell lung cancer patients. Patients received trilaciclib or placebo before E/P on days 1-3 of each cycle. Select end points were prespecified to assess the effect of trilaciclib on myelosuppression and antitumor efficacy.

RESULTS

A total of 122 patients were enrolled, with 19 patients in part 1 and 75 patients in part 2 receiving study drug. Improvements were seen with trilaciclib in neutrophil, RBC (red blood cell) and lymphocyte measures. Safety on trilaciclib+E/P was improved with fewer ≥G3 adverse events (AEs) in trilaciclib (50%) versus placebo (83.8%), primarily due to less hematological toxicity. No trilaciclib-related ≥G3 AEs occurred. Antitumor efficacy assessment for trilaciclib versus placebo, respectively, showed: ORR (66.7% versus 56.8%, P = 0.3831); median PFS [6.2 versus 5.0 m; hazard ratio (HR) 0.71; P = 0.1695]; and OS (10.9 versus 10.6 m; HR 0.87; P = 0.6107).

CONCLUSION

Trilaciclib demonstrated an improvement in the patient's tolerability of chemotherapy as shown by myelopreservation across multiple hematopoietic lineages resulting in fewer supportive care interventions and dose reductions, improved safety profile, and no detriment to antitumor efficacy. These data demonstrate strong proof-of-concept for trilaciclib's myelopreservation benefits.

CLINICAL TRAIL NUMBER

NCT02499770.

Abstract PD1-01: Trilaciclib (T), a CDK4/6 inhibitor, dosed with gemcitabine (G), carboplatin (C) in metastatic triple negative breast cancer (mTNBC) patients: Preliminary phase 2 results

Background: Cytotoxic chemotherapy-induced damage of hematopoietic stem and progenitor cells (HSPCs) results in acute toxicities consisting of multi-lineage myelosuppression, and late onset toxicities consisting of progressive bone marrow suppression with increased incidence of therapy-related myeloid neoplasms. T is an IV CDK4/6 inhibitor in development to preserve HSPC and immune system function during cytotoxic chemotherapy (myelopreservation). Proof of concept for myelopreservation with T was observed in a randomized, placebo-controlled Phase 2 trial in small-cell lung cancer patients receiving 1st-line chemotherapy. This trial in mTNBC patients (NCT02978716) was designed to explore the utility of T in combination with GC.

Methods: This Phase 2, randomized, open-label study enrolled patients in the US and EU with mTNBC who had received 0-2 prior systemic cytotoxic therapies in the locally recurrent or metastatic setting and had no symptomatic brain metastases. Patients were randomized (1:1:1) to GC alone (Group 1) or T plus GC (Group 2) using a standard schedule (D1, 8 every 21 days) or to an alternative schedule (T on D1, 2, 8 and 9 with GC on D2 and 9 every 21 days; Group 3). On those days when both T and GC were scheduled, T was administered iv prior to GC infusion. Prophylactic growth factors were not administered in cycle 1; otherwise supportive care was allowed as needed. Primary objectives were safety and tolerability; tumor response was evaluated using RECIST v1.1 and PFS and OS were assessed. Myelopreservation endpoints reflecting the potential effects of T on multiple cellular lineages include occurrence of Grade 4 neutropenia (primary), RBC and platelet transfusions (primary), and lymphocyte counts with immune profiling (secondary and exploratory). A signature of CDK4/6 independence developed from preclinical data will be used to evaluate archival tumor tissue samples and data analysis is ongoing.

Results: 95 patients were dosed; median age 57 years (range 32,86), ECOG PS 0 (53%) or 1 (47%), 25% had liver metastases at baseline, and approximately 50% had received no systemic therapy in the recurrent/metastatic setting. Fifty-five patients remain on treatment. Disease progression was the most common reason for drug discontinuation (22/40; 55%). Overall the most common (≥ 25%) TEAEs were anemia (47%), nausea (35%), fatigue (34%), neutropenia (32%), platelet count decreased (25%), and vomiting (25%). The most frequent (≥ 15%) Grade 3 or 4 TEAEs were hematologic toxicities, i.e. neutropenia (28%), anemia (21%), neutrophil count decreased (21%) and thrombocytopenia (16%). These were also the most frequent drug-related TEAEs observed. Tumor efficacy data are being evaluated.

Conclusions: This trial, assessing the myelopreservation effects of T when combined with GC in patients with mTNBC, has completed enrollment. Myelopreservation data, immune profiling, as well as ORR and preliminary PFS results will be presented by study arm at the meeting.

Citation Format: O'Shaughnessy J, Wright GS, Thummala AR, Danso MA, Popovic L, Pluard TJ, Cheung E, Han HS, Daniel BR, Vojnovic Z, Vasev N, Ling M, Richards DA, Wilks ST, Milenkovic D, Sorrentino JA, Roberts PJ, Bomar M, Yang Z, Antal JM, Malik RK, Morris SR, Tan A. Trilaciclib (T), a CDK4/6 inhibitor, dosed with gemcitabine (G), carboplatin (C) in metastatic triple negative breast cancer (mTNBC) patients: Preliminary phase 2 results [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD1-01.

Structural comparisons of fibronectins isolated from early and late passage cells

Fibronectins isolated from culture media conditioned by the growth of early (young) and late (old) passage human fibroblasts were compared by affinity chromatography and polyacrylamide gel electrophoresis. The results indicated that fibronectins from young and old cells were similar, but not identical. The fibronectin synthesized by old cells migrated more slowly on NaDodSO4 polyacrylamide gels in the presence of reducing agent than did fibronectin from young cells. The apparent molecular weight difference for purified fibronectins compared on gradient gels was estimated to be 5-10 000 daltons. The molecular weight difference was also evident in unpurified fibronectins in whole conditioned media. Both young and old fibronectins formed disulfide bonded dimers in the absence of reducing agents indicating that the molecular weight difference was not generated by proteolytic cleavage at the C-terminus of the molecule. Further, both fibronectins were bound by heparin-Sepharose, thiol-activated-Sepharose, and gelatin-Sepharose resins. Comparison of peptide maps, generated by limited proteolytic digestion revealed several differences. In particular, a polypeptide of molecular weight approx. 160 000 was larger in old cell fibronectin than in young cell fibronectin. This polypeptide had heparin binding activity, but lacked affinity for gelatin.

Interaction of fibronectin with collagen: age-specific defect in the biological activity of human fibroblast fibronectin

Fibronectins isolated fro early-passage and late-passage (in vitro aged) human fibroblasts were shown to differ in their ability to support cell adhesion and to influence cell morphology. Because fibroblast adhesion requires interactions between fibronectin, the cell surface, and the component of the extracellular matrix, we examined those functions in isolated cellular fibronectin. In comparison to fibronectin isolated from early-passage cells, fibronectin from late-passage cells bound poorly to native collagen types I and II. No differences were observed in the binding of the two fibronectins to denatured collagen. The binding of both fibronectins to native collagen was similarly promoted by heparin. Cell binding activity was evaluated by using a Boyden chamber assay to measure chemotaxis in response to either fibronectin. No differences were detected in cell binding. Comparisons of molecular weights by NaDodSO4/polyacrylamide gel electrophoresis reveals that fibronectin from late-passage cells is larger than that from early-passage cells. That difference is observed both in fibronectins isolated from conditioned media and in fibronectins isolated from the cell layer. These data support the hypothesis that late-passage cells produce a structurally and functionally distinct fibronectin. The defective binding to native collagen may account for some aspects of the aged phenotype.

Lymphoblastoid cell variant in contact-mediated cell spreading

We have isolated a clone of human lymphoblastoid cells that is capable of undergoing the phenomenon of contact-mediated cell spreading in vitro. We have detected this behavior when using both transmission electron microscopy (TEM), and differential interference contrast microscopy. Upon cell-cell contact, cells become loosely adherent and then begin to extend cellular processes that contact other cells and the substrate. We have also selected a variant clone that has lost the capability for cell spreading. The adhesions-defective variant becomes adhesion-positive and appears morphologically identical with the adhesive cells only in response to specific amino sugars. In the presence of those sugars the adhesion response is correlated with a shift in the apparent molecular weight of an iodinatable component. We propose that contact-mediated cell spreading in lymphoblastoid cells is mediated by a non-transferable cell surface-associated glycoconjugate. The synthesis of that glycoconjugate is defective in the non-adhesive clone, unless the cells are grown in glucosamine or mannosamine.