Prognostic role of pretreatment plasma fibrinogen in patients with solid tumors: A systematic review and meta-analysis

BACKGROUND

Plasma fibrinogen may be involved in several stages of cancer progression. Clinical studies have demonstrated that pretreatment plasma fibrinogen is associated with poor survival in various cancers. The aim of this meta-analysis was to examine the prognostic effect of circulating fibrinogen in solid tumors.

MATERIALS AND METHODS

We searched Medline, EMBASE, Cochrane Database of Systematic Reviews, and meeting proceedings to identify studies assessing the effect of pretreatment plasma fibrinogen on survival of cancer patients. Pooled multivariable-adjusted hazard ratios (HRs) for overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) were estimated using random-effects models.

RESULTS

Data from 52 observational studies and 15,371 patients were summarized. An elevated baseline plasma fibrinogen was significantly associated with worse OS (pooled HR = 1.69; 95% CI = 1.48–1.92). The highest negative effect of elevated plasma fibrinogen on OS was demonstrated in renal cell carcinoma (pooled HR = 2.22), followed by head and neck cancer (pooled HR = 2.02), and colorectal cancer (pooled HR = 1.89). The adverse prognostic impact of high plasma fibrinogen remained in both non-metastatic and metastatic disease and patients of different ethnicity. Patients with high baseline fibrinogen had a significantly shorter DFS (pooled HR = 1.52) and CSS (pooled HR = 2.50).

CONCLUSIONS

An elevated pretreatment plasma fibrinogen significantly correlates with decreased survival in patients with solid tumors. Future clinical trials are warranted to determine whether plasma fibrinogen could be incorporated in cancer staging systems and whether fibrinogen-lowering therapies have a favorable effect on disease recurrence and mortality.

Eruptive cutaneous squamous cell carcinoma and psoriasis: response to cetuximab

Cutaneous squamous cell carcinomas (CSCCs) comprise 20-30% of nonmelanoma skin cancers (NMSCs), and continue to increase in incidence. We report a case of a patient with severe psoriasis who had recurrent and eruptive CSCCs on her leg, which were successfully treated with cetuximab and radiotherapy. The patient had successful long-term clearance of her skin tumours, with the additional finding of resolution of psoriasis while on cetuximab therapy.

Correlation of body mass index with toxicity and survival in locoregionally advanced head and neck cancer patients treated with induction chemotherapy and concurrent chemoradiotherapy

6074

Background: Concurrent chemoradiotherapy (CRT) offers high functional organ preservation rates for locoregionally advanced head and neck cancer (LRAHNC) patients, but is associated with significant acute and chronic speech and swallowing toxicity. Recently, body mass index (BMI) has been suggested as a predictor of head and neck cancer patient outcome. In this analysis we sought to determine the impact of BMI on survival and toxicity outcomes in LRAHNC patients treated with CRT. Methods: 220 LRAHNC patients were treated on a multiinstitutional protocol consisting of induction carboplatin and paclitaxel followed by CRT. CRT was delivered for 4–5 cycles; each 14-day cycle consisted of 5 days concurrent paclitaxel, continuous infusion 5-FU, hydroxyurea, and 1.5 Gy twice daily radiation followed by 9 days without any treatment. Each patient's pre-treatment BMI was classified as overweight (BMI >= 25) or non-overweight (BMI < 25). As an independent variable, BMI was analyzed as a predictor of IndCT or CRT toxicity, locoregional control, and overall survival. BMI was analyzed as categorical variable, and also a continuous variable in a multivariate proportional hazards model. Results: There was no association between BMI and IndCT toxicity. During CRT overweight patients had significantly lower rates (24/103 vs 42/112) of grade 3 or higher neutropenia (p = 0.027), mucositis (p = 0.05), dermatitis (p = 0.028) and higher rates of anorexia (p = 0.05). Overweight patients had 12% long term PEG tube rate, compared to 34% of non-overweight patients (p < 0.001). On pooled survival analysis, patients with BMI > 25 had significantly better overall survival outcomes (mean 81.2 months, 95% CI 75.1–87.3 months) than patients with BMI < 25 (median 58.2 months; mean 56.5 months, 95% CI 49.6–63.3 months) (log-rank p < 0.001). Conclusions: Our data suggest patients with pre-treatment BMI > 25 experience lower rates of toxicity commonly associated with chemoradiation, and have a significantly better prognosis than patients with BMI < 25. Although the mechanism of BMI as an independent predictor of outcomes is unclear, we are continuing to explore mechanisms underlying this association.

No significant financial relationships to disclose.

Mass spectrometry profile as a predictor of overall survival benefit after treatment with epidermal growth factor receptor inhibitors in head and neck squamous cell carcinoma

6000

Background: Our previous study has shown that a matrix-assisted laser desorption ionization (MALDI) mass spectrometry (MS) profile in serum or plasma can predict lung cancer patient survival after treatment with epidermal growth factor receptor inhibitors (EGFRI). We examined the ability of this same MALDI-MS profile in plasma or sera to predict for survival benefit of EGFRIs in patients with head and neck squamous cell carcinoma (HNSCC). Methods: Spectra were obtained in triplicate using MALDI-MS from 314 samples obtained from five HNSCC cohorts treated with 1) gefitinib (G, n = 100); 2) erlotinib and bevacizumab (E/B, n = 81); 3) cetuximab (C, n = 21); 4) surgery (S, n = 78); and 5) palliative chemotherapy (PC, n = 34). Each sample was classified into “good” or “poor” outcome groups and overall survival was examined using this MALDI-MS classifier (VeriStrat, Biodesix, Steamboat Springs, CO). Results: Successful classification could be achieved in 311/314 (98%) of the samples. In all EGFRI-treated cohorts, the classifier predicted survival benefit while the cohorts without EGFRI-treatment showed no survival difference by log-rank testing (G: p = 0.007, HR 0.41, 95%-CI 0.22–0.79; E/B: p = 0.02, HR 0.20, 95%-CI 0.05–0.78; C: p=0.06, HR 0.26, 95%-CI 0.06–1.06; and PC: p = 0.76, HR 0.88, 95%-CI 0.4–1.97), independent of performance status, age, gender and smoking history. Conclusions: This study suggests that the same predictive algorithm for MALDI-MS generated from patients with lung cancer treated with EGFRIs is also predictive of survival outcome in HNSCC patients treated with both TKIs and cetuximab, and may allow rational selection of patients most likely to benefit from an EGFRI monotherapy.

[Table: see text]

Phase I evaluation of vandetanib with radiation therapy (RT) ± cisplatin in previously untreated advanced head and neck squamous cell carcinoma (HNSCC)

6016

Background: Vandetanib is a once-daily oral anticancer agent that selectively targets VEGF, EGF and RET receptor tyrosine kinases. We report preliminary results from an ongoing open-label phase I study of vandetanib with RT ± cisplatin in patients (pts) with previously untreated, unresected, locally advanced (stage III-IV) HNSCC. Methods: Eligible pts received once-daily vandetanib for 14 days followed by either 1) concomitant vandetanib + RT (2 Gy/d, 5 d/wk; total 70 Gy) + cisplatin (30 mg/m2, 2 h iv infusion/wk) for 7 wks, or 2) concomitant vandetanib + RT (2.2 Gy/d accelerated fractionation, 5 d/wk; total 66 Gy) for 6 wks. The primary objective was to determine the safety, tolerability and maximum tolerated dose (MTD) of vandetanib in both regimens. The first pt cohort received vandetanib 100 mg/day; escalation to 200 mg and 300 mg in subsequent cohorts was permitted providing <2/6 (33%) pts in the preceding cohort experienced a dose-limiting toxicity (DLT). Cohort expansion at the MTD of vandetanib was also planned. Results: As of Dec 1 2008, 24 pts (median age 53.5 yrs; 19 male; all M0) had received treatment with vandetanib + RT + cisplatin (n=18) or vandetanib + RT (n=6). In the triplet arm, no DLTs occurred in the initial vandetanib 100 mg cohort (n=6); an additional 6 pts were enrolled to receive vandetanib 200 mg but this dose was considered to exceed the MTD since DLTs were reported in 3/5 evaluable pts (Table). Vandetanib 100 mg was therefore declared the MTD with RT + cisplatin and cohort expansion at this dose continues. In regimen 2), 6 pts have received vandetanib 100 mg + RT and evaluation of this initial cohort is ongoing. Conclusions: This study, which continues to recruit, is the first to evaluate dual targeting of VEGFR/EGFR tyrosine kinases with chemoradiation or radiation alone in HNSCC pts. Among the 24 treated pts, 2 have completed the 2-year follow up, 1 death occurred that was causally related to cisplatin, and 21 remain in follow up or continue to receive treatment.

[Table: see text]

[Table: see text]

Effects of vascular endothelial growth factor (VEGF) signaling inhibition on human erythropoiesis

3575

Background: In rodents, inhibition of VEGF signaling increases production of red blood cells. Major clinical trials of VEGF signaling inhibitors have not reported on these effects in human patients (pts). Methods: To determine whether disruption of VEGF signaling in humans is associated with increased erythropoiesis, we analyzed red blood cell (RBC) and hemoglobin (Hgb) measurements in pts at a single institution enrolled in a phase II trial of axitinib in advanced thyroid cancers (16 pts), a study of sorafenib in advanced solid tumors (57 pts), and a randomized phase II trial of concomitant fluorouracil, hydroxyurea, and radiation with (14 pts) or without bevacizumab (8 pts) for locally advanced cancers of the head and neck. In the axitinib and sorafenib trials, no pt received red cell transfusions (Tf) or erythropoiesis stimulating agents (ESAs). Three pts in the chemoradiotherapy study received Tf or ESAs and were excluded from further analysis. Erythropoietin (EPO) plasma concentrations were measured only on pts in the sorafenib study at baseline, and days 8 and 35. Mixed models with random intercept were used to determine the effect of VEGF signaling inhibitors on RBC and Hgb. Repeated measures analysis of variance was used to examine whether EPO levels changed over time. Results: Over the first 84 day interval of treatment RBC increased for each day on axitinib (4 K/mcl [95% CI 2, 7], p < 0.001) or sorafenib (3K/mcl [2, 4], p < 0.001). Similar results were detected for Hgb. For the first 68 day interval of chemoradiotherapy alone, the RBC declined over time (-13K/mcl/day [-16, -10]) but less so (-7K/mcl [-10, -5]) with added bevacizumab (interaction p = 0.003). EPO levels changed with sorafenib exposure, most notably, increasing by 38% between days 8 and 35 (p < 0.001 by Wilcoxon signed rank test). Conclusions: VEGF signaling inhibition is associated with increased RBC and EPO production. This effect might contribute to positive and negative clinical consequences of exposure to VEGF signaling inhibitors.

[Table: see text]

Functional organ preservation with definitive chemoradiotherapy for T4 laryngeal squamous cell carcinoma

BACKGROUND

Randomized trials established chemoradiotherapy as standard treatment for advanced laryngeal cancer. Patients with large-volume T4 disease (LVT4) were excluded from these trials. The purpose of this study was to report T4 laryngeal cancer patient outcome, including those with LVT4 disease, treated with chemoradiotherapy.

PATIENTS AND METHODS

This study is a retrospective subset analysis of 32 patients with T4 laryngeal carcinoma including LVT4 tumors treated on three consecutive protocols investigating paclitaxel (Taxol), 5-fluorouracil, hydroxyurea, and 1.5-Gy twice daily (BID) radiotherapy (TFHX).

RESULTS

Median follow-up is 43 months. Four-year locoregional control (LRC), disease-free survival (DFS), overall survival (OS), and laryngectomy-free survival (LFS) was 71%, 67%, 53%, and 86%, respectively. Four patients required laryngectomy for recurrent or persistent disease. Of disease-free patients with >or=1 year follow-up, 90% demonstrated normal or understandable speech. None required laryngectomy for complications. Among LVT4 patients, 4-year LRC, DFS, OS, and LFS was 71%, 65%, 56%, and 81%, respectively. Induction chemotherapy improved 4-year LRC (90% versus 46%, P = 0.03) and DFS (84% versus 42%, P = 0.03).

CONCLUSIONS

Promising control and functional outcomes are achieved with TFHX for T4 laryngeal patients. LVT4 disease had outcomes similar to patients with less advanced disease treated on Radiation Therapy Oncology Group 91-11. Induction chemotherapy improved outcomes, warranting further investigation.

pKDR/KDR ratio predicts response in a phase I/II pharmacodynamic study of erlotinib and bevacizumab for recurrent or metastatic head and neck cancer (HNC)

6021

Background: EGFR activation up-regulates VEGF, which has been correlated with resistance to anti-EGFR agents. We previously reported early results (Vokes, JCO, 2005) of a phase I-II study of the EGFR inhibitor erlotinib (E) with the VEGF antibody bevacizumab (B) in recurrent or metastatic HNC. We now present results from the pharmacodynamic analysis as well as updated outcome data. Methods: Phase I/II trial of fixed dose erlotinib (E) 150 mg orally daily with escalation of bevacizumab (B) to a maximum of 15 mg/kg q 3 weeks and continued at 15 mg/kg in the phase II portion. Pts were randomized to receive the initial bevacizumab dose on either day 1 or 15. Paired biopsies were taken at baseline and after 2 weeks of treatment (after E alone or E+B) and analyzed by immunofluorescence and laser scanning analysis for target inhibition and apoptosis markers (VEGFR2/KDR, EGFR, CD31, and respective activated forms [pKDR, pEGFR]). Results: Paired biopsies were available from 20 patients. At baseline pKDR/KDR (ratio) correlated with clinical outcome and differed significantly between responses (CR>SD: p<0.01; CR>PD: p<0.0005). Interestingly, endothelial cell EGFR levels also appeared to correlate with response (CR+SD>PD: p<0.03). Paired tissue samples showed that E or E +B treatment increased apoptosis in tumor cells (pre: 0.96%, post: 7.02%: p<0.05) and endothelial cells (pre: 0%, post: 12%: p=0.15). Further, E+B treatment reduced expression of endothelial KDR, EGFR and VEGF levels compared to E alone. We previously reported an overall response rate of 14.6% (48 evaluable patients in the phase II cohort). Updated median follow-up was 7.3 months (2.1 years for patients still alive). The updated median overall/ progression free survival was 7.3 months/ 3.9 months with 30.6%/ 8.2% of patients alive at 1/2 years. Conclusions: Compared to E alone the combination of E + B showed increased inhibition of endothelial survival factors. pKDR/KDR appears to predict response to E+B. The promising clinical efficacy of E+B and potential predictive biomarkers warrant further validation in larger cohorts. (Supported by NIH N01 CM-57018–16)

No significant financial relationships to disclose.

A phase 1b study of oral rapamycin (sirolimus) in patients with advanced malignancies

3510

Background: Rapamycin (R) analogues are being studied as cancer therapies since mTOR is recognized as a relevant target in several cancer types. However, R is readily available, has been well-studied in organ transplant patients, was the first recognized mTOR inhibitor, and demonstrates efficacy in preclinical cancer models. The aims of this study were to define R’s maximum tolerated dose (MTD), observed toxicities, dose-limiting toxicities (DLT), pharmacokinetics and effect on inhibition of phosphorylation of p70 S6 kinase (S6K) in peripheral T-cells (PTL). Methods: R was administered orally once weekly to successive cohorts of patients using an adaptive escalation design based on whole blood concentrations ([R]), using a validated HPLC procedure. S6K was assessed by stimulating CD3+ cells ex-vivo with PMA and ionomycin for 1 hour, followed by Western blot analysis using antibodies directed against phospho-Thr389 of S6K versus total S6K as a loading control. Results: 24 subjects have been enrolled in dose cohorts of 10 mg, 20 mg, 30 mg, and 60 mg. The mean [R] observed on day 2 of week 1 (24 hr after 1st dose) was 5.5±2.7, 11.6±6.0 and 22.6±10.7 ng/mL, for dose levels 10 mg, 20 mg and 30 mg, respectively. [R] decreased by ∼50% by day 4 of week 1 (2.7±1.0, 6.9±4.0 and 11.0±7.7 ng/mL, respectively). By day 1 of week 2 (prior to the next dose of R), [R] had decreased below the limit of quantitation (2 ng/mL) for all subjects at 10 mg, 3 of 7 at 20 mg, and 4 of 6 at 30 mg. Preliminary analysis suggests that sustained phospho-S6K inhibition was achieved in some patients at 30 mg. The most common toxicities observed included nausea (50%), diarrhea (42%), asthenia (38%), hyperglycemia (58%), anemia (46%), and lymphopenia (33%). DLTs observed include 1 patient with grade 3 pneumonia at 20 mg, 1 patient with grade 3 dehydration at 30 mg, and 1 patient with grade 3 asthenia at 60 mg. Stable disease has been observed in 46% of evaluable patients. Conclusions: R can be feasibly administered orally on a once weekly schedule with a similar toxicity and pharmacokinetic profile compared with other mTOR inhibitors. Preliminary evidence suggests that prolonged suppression of phospho-S6K in PTL is possible at well-tolerated doses.

No significant financial relationships to disclose.

A phase II study of axitinib (AG-013736 [AG]) in patients (pts) with advanced thyroid cancers

6008

Background: Elevated VEGF-A and VEGF-C have been reported in thyroid tumor tissue compared with normal thyroid. AG is a potent, small molecule inhibitor of VEGF receptors 1, 2 and 3. The efficacy and safety of AG therapy in pts with advanced thyroid cancers was examined in this single-arm, multi-center study. Methods: 60 pts with metastatic or unresectable locally-advanced thyroid cancer refractory to, or not suitable candidates for, 131iodine (131I) treatment, with measurable disease received AG at a starting dose of 5 mg orally BID. The primary endpoint was response rate (RR) by RECIST criteria. A Simon 2-stage minimax design was used (a=0.1; β=0.1; null RR=5%; alternative RR=20%). Samples were collected pretreatment and q8wks to explore relationships between clinical response and plasma soluble proteins. Results: Median age was 59 yrs (26–84), 35 (58%) were male. Histological subtypes included papillary: 29 pts (48%); follicular: 15 pts (25%)-11 (18%) with Hurthle cell variant; medullary: 12 pts (20%); anaplastic: 2 pts (3%), and other/unknown: 2 pts (3%). 53 pts (88%) had prior surgery, 42 (70%) had prior 131I treatment, 27 (45%) had prior external beam radiation, and 9 (15%) had prior chemotherapy. Partial response (PR) by investigator report was achieved in 13 pts (22% CI: 12.1, 34.2), with 31- 68% maximum tumor regression and duration of response (DOR) of 1–16 months. 30 pts (50%) have stable disease with a duration range of 4–13 months and 13–67% maximum tumor regression in 28 pts. Response assessments are ongoing. The treatment duration range is 6–670 days with 38 pts currently on study. Median PFS has not been reached with a median follow up of 273 days. The most common treatment-related adverse events were fatigue (37%), proteinuria (27%), stomatitis/mucositis (25%), diarrhea (22%), hypertension (20%) and nausea (18%). AG therapy consistently decreased soluble VEGFR2 and VEGFR3, and increased VEGF in the blood, demonstrating pharmacodynamic activity against targeted VEGF receptors. Conclusions: AG has substantial anti-tumor activity in advanced thyroid cancer with demonstrated pharmacodynamic activity. A global pivotal trial testing AG in doxorubicin refractory thyroid cancer is ongoing.

[Table: see text]

Updated results of a phase II trial integrating gefitinib (G) into concurrent chemoradiation (CRT) followed by G adjuvant therapy for locally advanced head and neck cancer (HNC)

6028

Background: This study was undertaken to evaluate the tolerability and efficacy of substituting G for paclitaxel into a well- described CRT regimen (Clin Cancer Res 9: 5936; JCO 21: 320) and continuing G as adjuvant therapy. Endpoints included complete response (CR) rate to CRT, progression-free (PFS), disease-specific (DSS) and overall survival (OS), and local & distant control rates. Methods: Previously untreated subjects with stage III, IVa, or IVb squamous cell, poorly differentiated carcinomas, or lymphoepithelioma were enrolled. Organ sparing surgery was allowed. Subjects received 2 cycles of carboplatin/paclitaxel induction followed by CRT with G (250 mg PO qd), 5- fluorouracil, hydroxyurea, and twice daily radiation on day 1–5 of five 14d cycles. G was continued for 2 years from the start of CRT. Results: From 2/03 to 10/04, 67 eligible subjects accrued including 51 males; median age 56; ECOG PS 0 in 47, 1 in 19, and 2 in 1; stage IV in 61 (91%). With median follow-up of 858 days, 9 have had progressive disease (PD, 3 distant, 5 local, 1 with both) and 15 have died (12 related to HNC). Estimated OS=83% at 2y, 73% at 3y; PFS=77% at 2y, 64% at 3y; and DSS=86% at 2y, 80% at 3y. In 56 evaluable subjects we observed 51 CR (91 %), 4 partial responses and 1 PD after CRT. Non-evaluable subjects underwent surgery prior to CRT (10), or died prior to evaluation (1). Grade 3/4 toxicity included mucositis (75%/10%), dermatitis (29%/3%), rash (4%/0%) and diarrhea (1%/0%). Sixty-two patients received maintenance gefitinib, with 60 reliably reporting doses (median days on gefitinib=667). Reasons for holding G included LFT abnormalities, patient refusal, diarrhea, rash, recurrence, hospitalization for acute illness, and early death. Conclusions: Adding G to concurrent CRT after induction therapy, and as adjuvant therapy is tolerable and feasible. Favorable survival and CR data suggest that this is a promising regimen for patients with locally advanced HNC.

[Table: see text]

Prognostic factors for clinical benefit after epidermal growth factor receptor (EGFR) directed therapy in squamous cell carcinomas of the head and neck (SCCHN)

6025

Background: Single agent EGFR tyrosine kinase inhibitors (TKI) have demonstrated reproducible response rates of 5–15% in treatment of SCCHN. The subset of patients that benefits most from these agents remains unknown. We undertook a review of data from 5 clinical trials administering EGFR TKI in order to determine if there are clinical characteristics that are associated with response or benefit. Methods: We reviewed individual patient data from 5 clinical trials of erlotinib, lapatinib, or gefitinib. The primary endpoint was association of clinical variables with clinical benefit, defined as response (CR or PR) and stable disease (SD) >4 months. Secondary correlative endpoints included progression-free survival (PFS) and overall survival (OS). Logistic regression and Cox proportional hazard models were used to conduct univariate and multivariate analysis. Results: 319 subjects were included in the analysis with a median age of 59 years, 79% male. Disease status at start of therapy was local only in 43%, metastatic only in 29%, and both in 27%. Performance status (PS) was 0 in 25%, 1 in 62%, and 2 in 13%. Observed responses were: 1% CR, 6% PR, 24% SD >4 mo, 18 % SD3 in 6%) and diarrhea (grade 1 in 30%, grade 2 in 10%, grade 3 in 5%). Lower PS (p=0.06, OR (0/2)=3.1), age 70+ (p=0.02, OR= 2.1), and development of rash (p<0.01, OR=3.6), and diarrhea (p=0.03, OR=1.8) were associated with higher response rates. These variables were also associated with longer OS and PFS. Conclusions: Clinical parameters that appear to predict response to EGFR TKI include PS and age. EGFR mechanistic toxicities that develop during therapy are highly associated with benefit and suggest a relationship between drug exposure and outcome.

No significant financial relationships to disclose.

Randomized phase II study of concomitant chemoradiotherapy with 5-fluorouracil-hydroxyurea (FHX) compared to FHX and bevazicumab (BFHX) in intermediate stage head and neck cancer (HNC)

6034

Background: Preclinical data supports inhibition of vascular endothelial growth factor (VEGF) to improve tumor radiosensitivity. Phase I data demonstates that BFHX was tolerable in HNC (Seiwert, pASCO2006). Here we present preliminary toxicity data from a randomized phase II trial in pts with PS 0–2, stage II-IV (T2–4 N0–1 M0) HNC. Methods: Pts were randomized (2:1) to receive either BFHX or FHX. Planned sample size is 72pts. Chemotherapy consists of 5- FU (600 mg/m2/day continuous infusion for 120 hrs), hydroxyurea (500 mg PO q12 hours for 11 doses) with or without bevacizumab (10 mg/kg IV on day 1), concurrently with twice daily RT on a week on-week off schedule. Results: 21pts (BFHX 14pt and FHX 7pt) have completed therapy and are evaluable for toxicity. Pt characteristics in the BFHX and FHX arms are: median age 61 vs. 55 yrs, males 78% vs. 85%, stage II-III 57% vs. 86% and IV 43% vs. 14%. All pts have PS 0–1. 20 pts are evaluable for toxicity. Two episodes of gr3 leukopenia and one episode of gr 3 neutropenia were observed in the BFHX arm; whereas no gr3 hematologic toxicities were seen in the FHX arm. Mucositis (Gr3 - BFHX 85% vs. FHX 86%) and dermatitis (Gr3 - 0% vs. 14%) were observed in every pt. Other common non- hematologic toxicities were pain (100% vs. 86%), fatigue (77% vs. 86%) and anorexia (62% vs. 51%). No hemorrhagic events were observed. In the BFHX arm, one episode of deep venous thrombosis and one non-neutropenic death from sepsis were observed. Pathologic complete response rates were 92% and 100% in the BFHX and FHX arms, respectively. Conclusions: Preliminary results support the tolerability of BFHX. Toxicity appears to be similar to FHX with an apparent increase in leukopenia consistent with prior reports. Bleeding complications were not increased with BFHX.

No significant financial relationships to disclose.

Phase I study of rapamycin (R) in combination with CYP3A4 modifier, ketoconazole (K), in patients with advanced malignancies

3061

Background: R is currently FDA approved for the treatment of renal allograft rejection but mTOR is a relevant target in several cancer types. K, a CYP3A4 inhibitor, increases the area under the concentration curve (AUC) of R and co-administration of R and K can overcome poor R bioavailability and decrease costs substantially. The aims of this study were to find the maximum tolerated dose (MTD) and dose-limiting toxicities (DLT) of R administered weekly in combination with K and describe the pharmacokinetics (PK) of the combination in patients with advanced malignancies. Methods: R and K were administered concurrently to successive cohorts of patients. R starting dose was 1 mg once weekly and was escalated by 1 mg per dose level. K was administered at a constant dose of 200mg BID 1 day prior to each R dose then 200 mg QD on the next 3 consecutive days. Results: 34 subjects (median age 60 years) have been enrolled. The highest dose of R administered thus far was 5mg without DLT. Most frequent toxicities observed of any grade included hyperglycemia (41%), lymphopenia (35%), hyperlipidemia (35%), fatigue (29%), anemia (26%), anorexia (24%), and nausea (24%). Observed grade 3 toxicities included 2 patients with lymphopenia, 2 patients with elevated transaminases, and 1 patient each with emesis and hyperglycemia. One patient experienced grade 3 confusion likely due to a drug-drug interaction of K with concomitant psychotropic medications. PK analysis of the first 2 dose levels confirms that K significantly increases Cmax and AUC of R ( Table ). R Cmax (with K) averaged 22.5 (11.7) and 27.4 (7.9) (mean/SD) ng/ml at the 1 and 2 mg dose levels, respectively. R AUC (with K) averaged 408.9 (225.4) and 663.8 (201.8) (mean/SD) ng*h/ml at the 1 and 2 mg dose levels, respectively. Conclusions: Low dose weekly R plus K results in potentially efficacious concentrations, as demonstrated by classic mTOR inhibitor toxicity. Higher doses on this schedule without K are probably also feasible, but would have higher costs.

[Table: see text]

No significant financial relationships to disclose.

A Phase II study of axitinib (AG-013736), a potent inhibitor of VEGFRs, in patients with advanced thyroid cancer

5529

Background: Elevated levels of VEGF have been found in thyroid tumor tissue compared to normal thyroid. Axitinib (AG-013736) is a novel small molecule inhibitor of the receptor tyrosine kinases with picomolar potency against VEGFR 1, 2 & 3 and nanomolar potency against PDGFR-beta and KIT. A phase I study in solid tumors identified 5 mg BID as the therapeutic dose. A phase II study in renal cell cancer demonstrated significant efficacy with a response rate (RR) of 46% (Rini et al, ASCO 2005). This study examined the safety and efficacy of AG-013736 (AG) therapy for advanced thyroid cancer. Methods: 32 patients (pts) refractory to or not suitable candidates for Iodine (131I) treatment were treated with AG 5 mg p.o. BID. Eligibility included measurable disease and ECOG performance status (PS) of 0 or 1. A Simon 2 stage minimax design was used (alpha = 0.1; beta = 0.1; null response rate (RR) = 5%; alternative RR = 20%). Results: The median age of 32 enrolled pts was 63 yrs (35–81), 20 (63%) were male, 12 (38%) were female. Histological subtypes include papillary: 19 pts (59%); follicular- 9 pts (28%), medullary- 2 pts (6%) and anaplastic-2 pts (6%). 25 pts (78%) had prior surgery, 19 pts (59%) had prior 131I treatment, 15 pts (47%) had prior RT, 6 pts (19%) had prior Adriamycin. Best response as assessed by RECIST criteria is PR in 3 pts with 38%-48% regression and additional unconfirmed PRs in 3 pts. Two pts (follicular) have PR>12 mos. Response assessments are ongoing. 12 patients have discontinued treatment: 6 pts (19%)-progression, 3 pts-adverse events (AEs) and 3 pts-other. Twenty pts (63%) remain on study. The range for time on study is (6, 469) days. Median progression free survival has not been reached. Preliminary safety data for 17 pts indicate most common treatment emergent AEs as fatigue (9 pts), nausea (5 pts), proteinuria ( 5pts ), dizziness (4pts). Gr. 3 AEs include proteinuria ( 2pts ), cough (1pt), dyspnea (1 pt), abdominal pain (1pt), dysphagia (1pt), fatigue (1pt), muscle weakness (1pt), anorexia (1pt). Gr. 2 hypertension was observed in 2 pts. Conclusions: AG-013736 has substantial anti-tumor activity in advanced thyroid cancer. Therapy is well tolerated with manageable toxicity. Further investigation in this setting is warranted.

[Table: see text]

Sequential evaluation of reduced radiotherapy doses in a phase II trial of induction chemotherapy (IndCT) followed by concomitant chemoradiotherapy (CTX) for advanced head and neck cancer (HNC)

5528

Background: CTX constitutes a standard for locoregionally advanced HNC. IndCT may decrease distant failure rates (Brockstein Ann Oncol, 2003). The combination of these approaches has resulted in favorable early survival outcomes. CTX is limited by acute mucositis and long-term functional impairment. We examined the feasibility of lowering radiotherapy doses in sequential groups of patients (pts) to maintain high antitumor activity while decreasing toxicities. Methods: This was a 3-part, nonrandomized, phase II trial. Pts with stage IV (M0) HNC received 8 weeks of IndCT with carboplatin and paclitaxel (groups A & B ); carboplatin, AUC 2, and paclitaxel 135 mg/m2 weekly x 6; group C carboplatin AUC 6 day 1, and paclitaxel 100 mg/m2 days 1, 8, and 15 with cycle 2 beginning day 28. All pts received alternating week CTX with paclitaxel, infusional fluorouracil, oral hydroxyurea, and twice daily radiotherapy (T-FHX) (Kies JCO 2001). Radiotherapy to gross disease, high risk, and low risk microscopic disease consisted of group A (n = 68): 75, 60, 45 Gy; group B (n = 64): 75, 54, 39 Gy; group C (n = 90): 72, 51, 36 Gy. We have previously reported outcome data on groups A & B (Vokes JCO 2002 & Haraf CCR 2003). Results: A total of 222 pts were treated between 11/1998 and 2/2001. 74% were male, median age was 57. Best overall response (groups A/B/C): CR: 83/93/68%. With median follow-up time of 64/53/39 months; 3-year overall survival is 72%/67%/67% (logrank p = 0.76), progression-free survival 72%/65%/59% (logrank p = 0.44), time to progression (TTP, in which deaths prior to progression are censored unless due to treatment-related toxicity) 82%/86%/67% (logrank p = 0.019), and local control92%/97%/86% (logrank p = 0.10). Acute toxicities during concurrent chemoradiotherapy included grade 3/4 mucositis 72/2%; 65/11%; 57/8%; and dermatitis 47/15%; 19/26%; 28/2%. Conclusions: This 3-stage study suggests that acute toxicity can be reduced and high overall survival rates maintained while reducing doses of radiotherapy. The lower 3 year TTP rate in cohort C suggests a dose-response curve in the CTX setting. Schedule B may represent the best therapeutic index. Functional outcomes data are presented separately.

[Table: see text]

A phase I study of bevacizumab (B) with fluorouracil (F) and hydroxyurea (H) with concomitant radiotherapy (X) (B-FHX) for poor prognosis head and neck cancer (HNC)

5530

Background: Increased VEGF levels are found in HNC. Preclinical data suggest synergistic antitumor activity of B with radiation and chemotherapy. We conducted a Phase I dose escalation study to determine the maximum tolerated dose and dose limiting toxicity (DLT) of B, when added to infusional 5-FU, Hydroxyurea (HU), and daily radiotherapy administered every other week in patients (pts) with poor prognosis HNC. Methods: Eligible pts had recurrent, or newly diagnosed HNC with high risk of recurrence, ± metastatic disease requiring local control, ECOG PS ≤2, and life expectancy >12 weeks. Two week cycles were repeated 6–7 times (see table ). Results: 43 pts were treated (34 completed). DLT was reached at level 3 with 2 pts having gr 3 transaminase elevations and one pt gr 4 neutropenia. Treatment of 7 (6 evaluable) pts on level 4 resulted in one DLT (SMV thrombosis) and this dose level was chosen for expanded evaluation. In all level 4 pts (N = 27) gr 3 mucositis occured in 73.1% and gr 3 hand-foot syndrome in 15.4%. Additional gr 3 or worse toxicities in the expanded level 4 included: esophageal bleed (tumor bed, grade 5), stroke (grade 4), carotid rupture (3 wks post RT, grade 5), and neck ulceration with need for carotid stent (3 months post RT, grade 4). One sudden death of unclear etiology occurred. Median overall survival is 389 days. One/two year survival is 52.1/26%. Median survival for patients treated with re-irradiation for recurrent, non-metastatic HNC is 314 days; one/two year survival is 45.9/17.2%. With a median follow-up of 317 days 13 patients are still alive (12 are cancer free). Conclusions: B can be integrated with FHX chemoradiotherapy at a dose of 10 mg/m2 every 2 weeks. While B related toxicities are seen, there appears to be no major synergistic toxicity. Long term activity is observed in this very high risk patient population. A randomized phase II trial of FHX with or without B in a lower risk population is ongoing.

[Table: see text]

No significant financial relationships to disclose.

A phase II study of lapatinib in recurrent or metastatic EGFR and/or ErbB2 expressing adenoid cystic (ACC) and non-ACC malignant tumors of the salivary glands (MSGT)

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Background: The limited therapeutic index of chemotherapy in recurrent or metastatic MSGT provides a strong rationale for the evaluation of molecularly targeted agents in this disease. Lapatinib is a dual inhibitor of EGFR and ErbB2 tyrosine kinase activity. Expression of ErbB2 and EGFR has been associated with biological aggressiveness and poor prognosis in MSGT, respectively. We conducted a phase II study to determine the antitumor activity of lapatinib in MSGT. Methods: The main study has a two-stage design in which patients (pts) with progressive, recurrent or metastatic ACC, and immunohistochemically expressing at least 1+ EGFR and/or 2+ ErbB2, were treated with lapatinib 1500 mg PO daily. Each cycle consists of 4 weeks of continuous dosing. Pts with non-ACC MSGT of other histologies, meeting identical eligibility criteria, were treated in this trial as a single-stage, separate cohort. Results: Of 57 pts screened for this study, 29/33 (88%) ACC and 22/24 (92%) non-ACC pts expressed EGFR and/or ErbB2. Thirty-eight pts have been accrued to the study to date (20 ACC/18 non-ACC). The remaining 13 pts who were screened positive either declined entry or were ineligible for other reasons. Baseline data on 34 pts are: M:F = 25:9, median age 56 (range 38–80), PS 0:1:2 = 16:17:1, prior radiation:chemotherapy = 30:18. After 92 cycles of therapy, the most frequent adverse events experienced (as % of cycles) were diarrhea (54%), pain (52%), fatigue (52%), lymphopenia (39%), anemia (38%), hyperglycemia (38%) and dyspnea (34%). No grade 4 adverse events have occurred and only 8 pts experienced a grade 3 adverse event, primarily pain and dyspnea. No significant cardiac toxicity has been observed. Among 14 ACC pts evaluable for response so far: 9 have SD (range 2–9 cycles), 3 PD, and 2 died prior to cycle 2. For 12 evaluable non-ACC pts: 8 have SD (range 2–9 cycles), and 4 PD. No pts have had an objective response. Conclusions: Although there are no objective responses to date, lapatinib is well tolerated, with tumor stabilization achieved by 64% of pts and 24/38 pts remain on treatment at present. Trial accrual of ACC pts into the first stage has been completed, the second stage will open if an objective response is seen.

No significant financial relationships to disclose.

A phase II study of lapatinib (GW572016) in recurrent/metastatic (R/M) squamous cell carcinoma of the head and neck (SCCHN)

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Background: Epidermal growth factor receptor (EGFR) inhibitors have demonstrated reproducible activity in patients with R/M SCCHN. HER2 is the preferred dimerization partner for EGFR. Lapatinib is a dual EGFR and HER2 kinase inhibitor that has demonstrated promising preclinical activity in SCCHN models. Methods: This phase II multi-institutional study enrolls patients with R/M SCCHN into 2 cohorts: those without prior exposure to an EGFR inhibitor (arm A) and those with prior exposure to an EGFR inhibitor (arm B). All subjects were treated with lapatinib 1500mg OD. Primary endpoints were response rate (arm A) and progression-free survival (arm B). Results: 42 subjects have been enrolled (27 arm A, 15 arm B; 35 male, 7 female, median age 60 years). Toxicity was generally mild without any dose reductions or patient withdrawal due to adverse effects. Diarrhea was the most frequent toxicity occurring in 40% of patients. Other toxicities observed included fatigue (21%), rash (21%) and nausea (14%). 2 patients experienced grade 3 toxicity (1 diarrhea, 1 emesis). 1 patient had a reduction in left ventricular ejection fraction (60% to 40%) which was asymptomatic and recovered to baseline upon discontinuation of lapatinib. No objective responses were observed in either arm. In an intent-to-treat analysis stable disease was the best response observed in 37% of arm A and 20% of arm B subjects. Median PFS was 1.6 months in arm A and 1.7 months in arm B. Conclusions: Lapatinib as a single agent in R/M SCCHN, although well tolerated, appears to have little activity in either EGFR inhibitor naïve or refractory subjects.

No significant financial relationships to disclose.

ONYX-015. Onyx Pharmaceuticals

ONYX-015 (CI-1042), an adenovirus modified selectively to replicate in and kill cells that harbor p53 mutations, is under development by Onyx Pharmaceuticals for the potential treatment of various solid tumors, including head and neck, gastrointestinal and pancreatic tumors. It is a recombinant adenovirus that carries a loss-of-function mutation at the E1B locus, the product of which is a 55 kDa protein that binds to and inactivates the p53 tumor suppressor protein. Wild-type adenoviruses must disable this gene before viral replication can occur. This, the ONYX-015 adenovirus will leave normal cells unaffected. Mutations in the p53 tumor suppressor gene are the most common type of genetic abnormality in cancer, occurring in more than half of all major cancer types. Thus, these cells are susceptible to the virus, which will readily replicate and cause cell death. ONYX-015 is in ongoing phase III trials for the treatment of recurrent head and neck cancer, phase II trials for colorectal, ovary, pancreas and mouth tumors, and phase I trials for digestive disease, esophagus and liver tumors. Onyx Pharmaceuticals was granted US-05677178 covering methods for the treatment of p53-related cancers in October 1997. The patent specifically covers the use of modified adenoviruses and other DNA viruses, which lack viral proteins that bind to p53, for the treatment of cancer patients whose tumors lack p53 function. The USPTO awarded Onyx Pharmaceuticals US-05846945 in December 1998, covering methods for treating cancer using replicating adenoviral therapy in combination with chemotherapy. In April 1999, the company also received EP-094910177.8 covering the technology in Europe.

Treatment of metastatic urothelial cancer in the post-MVAC era

The combination of methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) has become the standard of care for metastatic urothelial cancer. Its efficacy has been proven in this setting but it can be a difficult regimen to tolerate. With the introduction of new active agents, different combinations are being evaluated. This article will highlight the use of these new regimens with emphasis on those employing gemcitabine or the taxanes.

Locally advanced non-small cell lung cancer

Locally advanced non-small cell lung cancer remains a paradoxical entity to manage. Although this type of cancer is confined to the thorax and is ostensibly curable, most patients presenting at this stage of disease eventually succumb to it. The accepted therapy presently includes chemotherapy and radiation. The exact agents, schedules, and combinations need to be defined further, although cisplatin has become the widely viewed standard cytotoxic drug in this setting. Notwithstanding, newer chemotherapeutic and biologic agents are being extensively tested to find less toxic options with greater efficacy. Drugs that are gaining widespread approval include carboplatin, paclitaxel, gemcitabine, and vinorelbine. At the same time, advances in radiation therapy are triggering a revolution in dose intensity and scheduling that will one day offer superlative local control.