Phase I-Phase II Trial of N-PhosphonacetyI-L-Aspartic Acid
`Given by Intravenous Infusion and 5-Fluorouracil Given
`by Bolus Injection 1,2
`
`Charles Erlichman, 3.4 Ross C. Donehower, 5 James L. Speyer, 6 Ray Klecker, 7 and Bruce A. Chabner 7
`
`ABSTRACT--A phase I clinical trial of N-phosphonacetyI-L-aspartic
`acid (PALA) and 5-fluorouracil (FUra) was performed on 30 patients.
`PALA was given as a 15-minute iv infusion once daily for 5 days, and
`FUra was given as a bolus injection on days 2, 3, 4, and 5. Cycles of
`treatment were repeated every 3 weeks. Dose-limiting toxicity was
`manifested by stomatitis and diarrhea. Skin rash was observed also
`but was not dose limiting. No consistent hematopoietic or renal toxicity
`was observed. Seventeen patients with disseminated metastatic mela-
`noma and measurable disease were evaluated for response. One
`partial response was seen; however, the response was associated with
`significant toxicity, and the treatment could not be repeated. Stable
`disease was observed in 3 patients with melanoma, 1 patient with colon
`carcinoma, and 1 patient with ovarian carcinoma. Our findings suggest
`that the clinical activity of PALA and FUra given according to the above
`schedule for melanoma is less than 25% (P<O.05). Pharmacokinetic
`studies of FUra revealed no consistent effect of PALA pretreatment on
`FUra disappearance in plasma. The mean FUra elimination half-life in
`plasma was 7.11 ___0.84 minutes (SEM), which is no different from that
`reported for FUra alone. The recommended doses on this schedule for
`phase II studies are 1,000 mg PALA/m2/day iv daily for 5 days and
`200 mg FUra/m2/day iv on days 2, 3, 4, and 5--JNCI 1982; 68:227-
`231.
`
`The use of combination chemotherapy has become com-
`monplace in the treatment of many neoplastic diseases. In
`general, drugs have been combined on the basis of their
`single-agent activity and their lack of overlapping toxicity
`for normal tissues. Some consideration also has been given
`to the ability of drugs to act at different phases of the cell
`cycle. Increasing interest is now being directed to drug
`combinations designed to take advantage of biochemical
`interactions at the cellular level. We report here a phase I
`trial of a combination of PALA and FUra, which was
`designed with the biochemical mechanisms of these agents
`in mind.
`PALA, a potent inhibitor of aspartate transcarbamylase,
`acts to inhibit de novo pyrimidine biosynthesis, as demon-
`strated in several murine solid tumors (1, 2). PALA has
`undergone extensive phase I (3, 4) and phase II trials (5-7)
`in humans over the last few years, but this agent has shown
`little clinical activity. FUra, a synthetic pyrimidine base
`analog, has been widely used in clinical chemotherapy for
`more than 20 years. In the cell, FUra is converted enzymat-
`ically to nucleotides. 5-Fluorouridine triphosphate is incor-
`porated into RNA, and 5-fluorodeoxyuridine monophos-
`phate potently inhibits cellular thymidylate synthetase. Pre-
`treatment with PALA before FUra administration could
`
`result in increased FUra nucleotide formation, inasmuch as
`PALA has been shown to decrease intracellular pyrimidine
`nucleotide pool size in some cell lines (8), and could result
`in less competing substrate for FUra conversion to nucleo-
`tides, incorporation into RNA, and inhibition of thymidyl-
`ate synthetase. Additionally, inhibition of the de novo path-
`way for pyrimidine biosynthesis by PALA might result in
`increased cellular levels of PRPP because of decreased use
`by this pathway. Drugs that increase PRPP levels, such as
`methotrexate, have been shown in vitro to result in enhanced
`FUra nucleotide formation (9).
`In support of this hypothesis that pretreatment with
`PALA would enhance FUra activity, animal studies have
`shown that PALA and FUra together have greater antitu-
`mor activity in CD8F1 mammary carcinoma (10), colon 38
`and 26 carcinomas, Lewis lung carcinoma, and M5076
`carcinoma than do single agents (11). On the basis of this
`hypothesis, a study of PALA and FUra was performed on
`patients with extensive malignant disease. A dose schedule
`was chosen that included pretreatment with PALA, to
`decrease intracellular pyrimidine nucleotide levels before
`administration of FUra.
`
`MATERIALS AND METHODS
`
`This phase I-phase II trial was conducted cooperatively
`by the Medicine Branch and the Clinical Pharmacology
`Branch of the National Cancer Institute. Entered in the
`study were 30 patients, 26-68 years old. The maIe:female
`
`ABBREVIATIONS USED: AUC=area under the curve; FUra=5-fluorouracil;
`PALA=N-phosphonacetyl-L-aspartic acid; PRPP=5-phosphoribosyl-l-py-
`
`rophosphate; t~half-life; WBC=white blood cell(s).
`
`1 Received May 4, 1981 ; accepted September 18, !981.
`
`z Research procedures were in accord with the ethical standards of the
`
`Clinical Research Committee, National Cancer Institute.
`s Fellow of the Medical Research Council of Canada.
`
`4 Department of Medicine, Princess Margaret Hospital, 500 Sherbourne
`
`St., Toronto, Ontario, Canada M4X 1K9.
`5 The Johns Hopkins Oncology Center, 600 North Wolfe St., Baltimore,
`
`Md. 21205.
`6 Division of Oncology, New York University Medical Center, 550 First
`
`Ave., New York, N.Y. 10016.
`7Clinical Pharmacology Branch, Division of Cancer Treatment, Na-
`
`tional Cancer Institute, National Institutes of Health, Public Health Ser-
`vice, U.S. Department of Health and Human Services, Bethesda, Md.
`
`20205.
`
`©
`
`©
`
`©
`
`227
`
`JNCI, VOL. 68, NO. 2~ FEBRUARY 1982
`
`Sandoz Inc. IPR2016-00318
`Sandoz v. Eli Lilly, Exhibit 1094-0001
`
`

`
`228 Erlichman, Donehower, Speyer, et al.
`
`ratio was 1.6:1. The presence of cancer in all 30 patients
`was pathologically confirmed: 18 had melanomas, 8 had
`carcinomas of the colon, 2 had carcinomas of the ovary, 1
`had a sarcoma, and 1 had carcinoma of the pancreas. Prior
`therapy with other chemotherapeutic agents (mean, two
`drugs) had been administered to 24 patients; 3 patients with
`carcinoma of the colon and 1 patient with carcinoma of the
`ovary had had prior FUra chemotherapy. The patient per-
`formance status was 30-90 on the Karnofsky scale; 24 of 30
`had a performance status greater than or equal to 50.
`Every 3 weeks patients received a daily 15-minute iv
`infusion of PALA for 5 consecutive days. FUra was given as
`a bolus injection shortly after completion of the PALA
`infusion on days 2, 3, 4, and 5. This dose schedule was
`chosen on the assumption that 1-day pretreatment with
`PALA would significantly decrease the levels ofintracellular
`pyrimidine nucleotides prior to administration of FUra.
`Dose escalation for new patients was permitted after a
`minimum of 3 patients had completed 2 therapy cycles. In
`the absence of known cumulative toxicity for either drug,
`dose escalation was allowed for patients who had successfully
`completed a therapy cycle with no toxicity. Two drug
`escalation programs were used. Initially, the PALA dose was
`1,500 mg/mZ/day for 5 days, and FUra was increased from
`100 to 150 to 250 mg/m2/day. The PALA dose was then
`decreased to 1,000 mg/mZ/day, and FUra was escalated
`from 150 to 200 to 250 mg/m2/day. The 6 patients who
`received 700 mg PALA/m2/day and 150 mg FUra/m2/day
`had developed significant toxicity at a higher dose level in
`this trial. Patients were considered to be assessable for acute
`toxicity if they completed one course of therapy.
`Skin and gastrointestinal toxicities were graded 1 ÷ to 3+
`according to the following criteria: Patchy areas of skin
`involvement were considered 1+, generalized skin involve-
`ment was graded 2+, and patients experiencing generalized
`exfoliation were assigned 3+. Patients who had loose bowel
`movements (<4 movements/day and none at night) or
`minimal stomatitis were considered to have 14- gastrointes-
`tinal toxicity. Frank diarrhea (>4 movements/day) and/or
`stomatitis, which was uncomfortable but still permitted oral
`intake of food, was graded 24-. A 34- gastrointestinal toxicity
`was assigned to patients having diarrhea with guaiac-posi-
`tive stool and/or severe stomatitis associated with an inabil-
`ity to ingest any liquids or solids.
`Pharmacologic studies were performed on selected pa-
`tients at dose levels of 100, 200, and 250 mg FUra/mz. By
`means of a high-pressure liquid chromatography technique
`(12), drug levels in plasma were monitored for 2 hours after
`the FUra iv bolus injection (12).
`
`RESULTS
`
`Renal function before therapy, as indicated by 24-hour
`creatinine clearance, was assessed in 22 patients: 14 had
`normal renal function (clearance -->70 ml/min), 7 had mod-
`erate impairment of renal function (clearance <70 but ->40
`ml/min), and 1 had marked renal impairment (clearance
`<40 ml/min). In 8 patients for whom information on cre-
`atinine clearance was not available, the blood urea nitrogen
`was normal in all, and serum creatinine was less than 1 mg/
`
`JNCI~ VOL. 68, NO. 2~ FEBRUARY 1982
`
`TABLE 1.--PALA and FUra dose levels
`
`Dose level, mg/m2/day
`
`PALA
`
`FUra
`
`No. of pa-
`tientsa
`
`No. of therapy
`courses
`
`700
`1,000
`1,000
`1,000
`1,500
`1,500
`1,500
`
`150
`150
`200
`250
`100
`150
`250
`
`6
`1
`21
`2
`2
`4
`3
`
`15
`3
`59
`8
`4
`6
`3
`
`Due to dose escalation in some patients, the total number is >30.
`
`100 ml in 6. Serum creatinine values of 1.3 mg/100 ml were
`recorded for 2 patients. The total bilirubin level in all 30
`patients was normal. All patients except 2 had WBC counts
`of 3,500 or more/mma. The WBC counts for these 2 were
`3,200 and 3,100/mma. All patients had platelet counts
`greater than 100,000/ram3.
`One patient died before completion of 1 cycle of therapy
`due to progression of the disease and was not included in
`toxicity evaluations. For the remaining 29 patients, the dose
`levels evaluated and the number of patients and therapy
`courses administered at each level are summarized in table
`1. Six patients received 1 cycle of therapy only, 17 patients
`received between 2 and 5 cycles, and 5 patients received
`between 6 and 10 cycles. One patient received more than 14
`therapy cycles.
`The major clinical toxicities affected the skin and gas-
`trointestinal tract and are summarized in tables 2 and 3.
`Skin toxicity was manifested most commonly by a macular,
`erythematous eruption that occasionally was pruritic. It
`usually began on days 5-8 of a cycle and was resolved in
`approximately 10-14 days. Skin toxicity did not occur con-
`sistently with each cycle. Prior chemotherapy or radiother-
`apy did not appear to predispose patients to skin toxicity.
`Although skin toxicity was a common occurrence, at none
`of the dose levels evaluated was it dose limiting.
`Gastrointestinal toxicity was the dose-limiting toxicity for
`the PALA-FUra combination used in this study. The major
`symptoms were mucositis and severe diarrhea. All 3 patients
`treated at a dose level of 1,500 mg PALA/mZ/day and 250
`mg FUra/m2/day developed severe mucositis and diarrhea
`with guaiac-positive stool. One patient treated at 1,500 mg
`PALA/m2/day and 250 mg FUra/m2/day became hypo-
`volemic, secondary to fluid loss from diarrhea, and devel-
`oped renal failure. Careful management of these complica-
`tions reversed the renal failure and the patient recovered.
`
`TABLE 2.--Skin toxicity
`
`Dose level, mg/m2/
`day
`
`Toxicity grade
`
`PALA
`
`FUra
`
`1÷
`
`2+
`
`3+
`
`No. of toxic
`therapy
`courses/total
`No. of courses
`
`700
`1,000
`1,000
`1,000
`1,500
`1,500
`1,500
`
`150
`150
`200
`250
`100
`150
`250
`
`1
`3
`21
`3
`0
`3
`3
`
`1
`0
`2
`0
`0
`1
`0
`
`0
`0
`0
`0
`0
`0
`0
`
`2/15
`3/3
`23/59
`3/8
`0/4
`4/6
`3/3
`
`Sandoz Inc. IPR2016-00318
`Sandoz v. Eli Lilly, Exhibit 1094-0002
`
`

`
`TABLE 3.--Gastrointestinal toxicity
`
`Dose level, mg/m2/
`day
`
`Toxicity grade
`
`PALA
`
`FUra
`
`1÷
`
`2+
`
`3+
`
`No. of toxic
`therapy
`courses/total
`No. of courses
`
`700
`1,000
`1,000
`1,000
`1,500
`1,500
`1,500
`
`150
`150
`200
`250
`100
`150
`250
`
`3
`0
`26
`4
`3
`0
`0
`
`0
`1
`7
`0
`0
`1
`0
`
`0
`0
`2
`1
`0
`2
`3
`
`3/15
`1/3
`35/59
`5/8
`3/4
`3/6
`3/3
`
`At 1,500 mg PALA/mZ/day and 150 mg FUra/mZ/day, 2
`patients developed significant gastrointestinal toxicity man-
`ifested by prolonged oral mucositis. At 1,000 mg PALA/
`m~/day and 200 mg FUra/m2/day, most episodes of toxicity
`were relatively mild and tolerable. However, 2 of 59 therapy
`courses were associated with significant mucositis, which
`varied from angular stomatitis to complete oral mucosal
`ulceration. The mucositis began most commonly on day 4
`and lasted 2-14 days. Diarrhea usually began during the
`second week of a cycle and was associated with occasional
`cramping. Gastrointestinal toxicity appeared to depend on
`the dose of FUra given with 1,500 mg PALA/m2, but this
`relationship was not demonstrated when the PALA dose
`was 1,000 mg/m~. Three patients complained of a gritty
`sensation in the eyes and photophobia. Two of these had
`obvious conjunctivitis. None of the three had any visual
`acuity disturbance, and ophthalmoscopic examination did
`not reveal any retinal abnormalities.
`Hematologic toxicity was assessed by measurement of
`WBC and platelet counts during the course of therapy (table
`4). For 52 of 98 therapy courses, nadir blood counts were
`available for assessment of hematologic toxicity. No patient
`developed a platelet count of less than 50,000/mm3. Five
`courses of therapy were associated with a fall in platelet
`counts to less than 100,000 but greater than 50,000/mma.
`After receiving 1,500 mg PALA/m~/day and 100 mg FUra/
`m~/day, 1 patient developed a platelet count of 73,000/
`mma. A second patient on 2 cycles of 1,000 mg PALA/m~/
`day and 250 mg FUra/m~/day developed platelet counts of
`95,000 and 59,000/mma. This patient had platelet counts of
`74,000 and 59,000 when treated with 2 cycles at 1,000 mg
`PALA/m~ and 200 mg FUra/mZ/day. The WBC nadir was
`less than 2,000 in 2 patients both treated with 1,000 mg
`PALA/m~/day and 200 mg FUra/m~/day. One of these
`individuals had been treated previously with cisplatin, chlo-
`rozotocin, and BCG. The other patient had received no
`previous therapy.
`While receiving PALA-FUra therapy, 5 patients devel-
`oped neurologic abnormalities. The 2 patients who had
`generalized seizures on 1,000 mg PALA/m~/day and 200
`mg FUra/m~/day were simultaneously documented to have
`central nervous system metastases. One patient treated with
`1,500 mg PALA/m~/day and 250 mg FUra/m2/day had
`focal seizures during a period when he was uremic and had
`a serum creatinine of 12.2 mg/100 ml. In 2 patients in
`whom bizarre affects and thought disorders were observed,
`no underlying central nervous system lesions were found. In
`1 of these patients treated with 1,000 mg PALA/mZ/day
`
`Phase I-II Trial of PALA and FUra 229
`
`and 150 mg FUra/m’~/day, the abnormal behavior was
`resolved when chemotherapy was suspended. However, in
`the other who received 1,500 mg PALA/m~/day and 150
`mg FUra/m2/day, no improvement occurred after therapy
`was stopped.
`Due to disease progression, 24 patients were removed
`from the study, and 2patients died from the disease during
`the study. Two were removed from the study after they
`refused further therapy. Two at this writing have stable
`disease and continue in the study. The 17 patients with
`pathologic diagnosis of melanoma were treated at adequate
`doses that produced mild but significant toxicity, and all
`had measurable disease. No patient had a complete re-
`sponse. One developed a partial response with greater than
`50% decrease in a skin nodule and lung metastases. Another
`patient had a mixed response: a greater than 50% decrease
`in the size of skin lesions but developed liver metastases on
`therapy. Three patients with melanoma were considered to
`have stable disease for 2 and 3 months. None of these
`patients had had previous FUra therapy. One patient with
`ovarian carcinoma, who had previously received FUra, was
`stable for 10 months, and another with colon carcinoma was
`stable for 4 months.
`Pharmacologic studies were performed on 9 patients.
`Maximum plasma FUra levels were 3.27 mM at a dose of
`250 mg/m~. Plasma FUra levels dropped below the level of
`assay sensitivity (5X10-8 M) within 60 minutes. In some
`patients, a distinct bi-exponential decline could not be
`
`TABLE 4.--Hematologic toxicity
`
`Myelosuppression indicator
`
`Platelets, <100,000 but >50,000/mm3
`
`WBC, <2,000/mma
`
`Dose level, mg/
`m2/day
`
`PALA
`
`FUra
`
`1,500
`1,500
`1,000
`1,000
`
`100
`250
`200
`200
`
`No. of
`therapy
`courses"
`
`1
`2
`2
`2
`
`a Hematologic toxicity data were available for 52 of 98 administered
`
`courses.
`
`I0 20 50 40 50 60 O I0
`Time,
`
`20
`
`so ,~o ~o
`
`TEXT-FIGURE 1.--Plot of plasma FUra vs. time. A) Patient was treated
`with 250 nag FUra/m2. B) Patient was treated with 200 mg FUra/m2.
`
`JNCI~ VOL. 68~ NO. 2, FEBRUARY 1982
`
`Sandoz Inc. IPR2016-00318
`Sandoz v. Eli Lilly, Exhibit 1094-0003
`
`

`
`230 Erlichman, Donehower, Speyer, et al.
`
`TABLE 5.--FUra pharmacokinetics
`
`Dose level, AUC,
`Patient mg/m2/day
`
`k, min-~a
`
`t~, minb
`
`mmol.
`min/liter
`
`PALA FUra
`
`1,500
`1,500
`1,500
`1,500
`1,000
`1,000
`1,000
`1,500
`1,500
`
`100
`100
`100
`200
`200
`200
`200
`250
`250
`
`#1
`#2
`#3
`#-4
`#5
`#6
`#7
`#8
`#9
`
`0.0801
`0.124
`0.0633
`0.0875
`0.0668
`0.1011
`0.1559
`0.138
`0.164
`
`8.65
`5.57
`10.94
`7.88
`10.38
`6.85
`4.44
`5.02
`4.24
`
`0.545
`0.047
`0.029
`0.360
`1.800
`0.550
`0.319
`1.86
`1.64
`
`Plasma FUra elimination rate constant.
`Plasma FUra elimination t½.
`Correlation coefficient (r) from linear regression of 10-60 min Log
`FUra levels vs. time.
`
`clearly defined because of difficulties in obtaining adequate
`numbers of early samples during this distribution phase
`(text-fig. 1). Therefore, individual FUra profiles were ana-
`lyzed in terms of a pharmacokinetic, one-compartment,
`open model similar to that of MacMillan et al. (13). The
`dose levels, plasma FUra elimination rate constant k, plasma
`FUra elimination t½, and the AUC are summarized in table
`5. The mean t½ was 7.11+0.84 minutes (SEM). The mean
`AUC values obtained in this analysis did not increase
`linearly with dose, but a rapid nonlinear increase in the
`mean AUC level was observed for those patients treated
`with 250 mg FUra/m2/day (text-fig. 2).
`
`DISCUSSION
`
`An initial trial of PALA given as a 15-minute daily iv
`infusion for 5 days and FUra on days 2, 3, 4, and 5 as a
`bolus injection, repeated every 3 weeks, demonstrated dose-
`limiting toxicity to gastrointestinal mucosa. The major tox-
`icity of PALA as a single agent is manifested in the skin and
`gastrointestinal organs, whereas FUra when given by bolus
`injection most commonly results in myelosuppression. How-
`ever, gastrointestinal and skin toxicity can occur with FUra
`even when given by bolus injection. Therefore, it is difficult
`to attribute the toxicity observed in this study to either
`agent alone. In 2 patients, neurotoxicity occurred that was
`not explained by causes other than drug administration.
`Inasmuch as neurologic abnormalities secondary to admin-
`istration of PALA have been reported (14), and because
`FUra is known to occasionally cause neurologic problems,
`the neurotoxicity of the 2 patients may be due to both drugs.
`Conjunctivitis and photophobia after PALA administration,
`which occurred in 3 patients, previously were not reported
`(3, 4), but these conditions may occur after FUra adminis-
`tration.
`This study involved the treatment of numerous patients
`with melanoma because other clinical trials were being
`conducted at the time for patients with this diagnosis at the
`National Cancer Institute. Patients who failed those trials
`were eligible for our study. A partial response was experi-
`enced by 1 of 17 patients with melanoma. However, this
`patient, treated with 1,500 mg PALA/mZ/day and 250 mg
`
`JNCI, VOL. 68, NO. 2, FEBRUARY 1982
`
`rc
`
`-0.893
`-0.999
`-0.944
`-0.995
`-0.975
`-0.994
`-0.936
`-0.995
`-0.983
`
`FUra/m2/day, developed severe diarrhea with associated
`hypovolemia and subsequent acute tubular necrosis. Careful
`management reversed the renal failure and the patient
`recovered, but subsequent courses of treatment with PALA
`and FUra could not be administered to him. Our findings
`suggest that this particular dose schedule for PALA and
`FUra would result in less than a 25% response rate (P<0.05)
`for patients with melanoma and, therefore, would not be a
`useful combination for clinical therapy of melanoma.
`The FUra pharmacokinetic studies on patients treated
`with PALA and FUra suggest two points: a) The plasma
`elimination t½ of 7.11 minutes that we observed is not
`different from that reported by others in single-agent studies
`(13). This implies that any enhanced toxicity observed for
`the PALA-FUra combination was not due to a change in
`plasma clearance of FUra by PALA. Because PALA is
`excreted primarily by a renal mechanism and is not highly
`protein-bound and FUra is primarily metabolized, phar-
`macokinetic interaction between these agents in plasma
`would not be expected. Such a conclusion is supported by
`our studies. Therefore, it is more likely that any enhanced
`toxicity is the result of an interaction at the cellular level, b)
`A saturable mechanism in the elimination of FUra is sug-
`gested by the nonlinear relationship between the AUC and
`the administered FUra dose. This interpretation must be
`made cautiously because of the small numbers of patients
`treated at each dose level and the wide variation in the
`calculated AUC; however, this interpretation agrees with
`suggestions made in other reports (15, 16).
`The dose schedule in this study was chosen to take advan-
`
`/
`/
`/
`/
`/
`/
`
`/
`
`200
`~oo
`FUra, mg/m2
`
`300
`
`T~XT-FmURE 2.--Plot of mean AUC vs. FUra dose level. Error bars represent
`SEM.
`
`Sandoz Inc. IPR2016-00318
`Sandoz v. Eli Lilly, Exhibit 1094-0004
`
`

`
`Phase I-II Trial of PALA and FUra 231
`
`tage of the mechanism proposed for PALA and FUra inter-
`action at the cellular level. We had previously noted that on
`the PALA schedule of a 15-minute infusion daily for 5 days,
`aspartate transcarbamylase levels in leukocytes were signif-
`icantly depressed within 24 hours of the first dose (17). If
`similar changes occur in other tissues, pyrimidine nucleotide
`levels would probably decrease in parallel by 24 hours after
`the first dose of PALA. Addition of FUra at that time could
`result in metabolism of this pyrimidine analog to active
`metabolites at a rate greater than that normally observed.
`However, a therapeutic benefit of this PALA-FUra dose
`schedule was seen in only 1 patient with melanoma. Other
`investigators using other schedules have reported responses
`in colon carcinoma, large cell carcinoma of the lung, fibrous
`histiocytoma, and sarcoma (18, 19). Although we found
`very limited activity of this drug combination in patients
`who had received prior chemotherapy for metastatic mela-
`noma, phase II studies with other dose schedules may be
`warranted on patients with other malignant diseases respon-
`sive to FUra. A schedule that involves PALA and FUra
`administration by continuous infusion may be more effica-
`cious than the one used in this study. Such a schedule may
`allow more incorporation of FUra into RNA throughout the
`cell cycle. For future phase II studies, we recommend 1,000
`mg PALA/mZ/day given iv over a period of 15 minutes for
`5 days and 200 mg FUra/m2/day given by bolus injection
`on days 2, 3, 4, and 5.
`
`REFERENCES
`
`(1) JOHNSON RK, INOUYE T, GOLDIN A, STARK GR. Antitumor activity of
`N-(phosphonacetyl)-L-aspartic acid, a transition-state inhibitor of
`aspartate transcarbamylase. Cancer Res 1976; 36:2720 2725.
`(2) JOHNSON RK, SWYRYD EA, STARK GR. Effects of N-(phosphonacetyl)-
`L-aspartate on murine tumors and normal tissues in vivo and in
`vitro and the relationship of sensitivity to rate of proliferation and
`level of aspartate transcarbamylase. Cancer Res 1978; 38:371-378.
`(3) ERL1CHMAN C, STRONG JM, WIERNIK PH, et a]. Phase I trial of N-
`(phosphonacetyl)-L-aspartate. Cancer Res 1979; 39:3992 3995.
`(4) VALDIVIESO M, MOORE EC, BURGESS AM, et al. Phase I clinical study
`of N-(phosphonacetyl)-L-aspartic acid (PALA). Cancer Treat Rep
`1980; 64:285-292.
`
`(5) CARROLL DS, GRALLA R J, KEMENY NE. Phase II evaluation of N-
`(phosphonacetyl)-L-aspartic acid (PALA) in patients with ad-
`vanced colorectal carcinoma. Cancer Treat Rep 1980; 64:349 351.
`(6) CREAGAN ET, AHMANN DL, INGLE JN, PURVlS JD III. Phase II study
`of N-(phosphonacetyl)-L-aspartate (PALA) in disseminated malig-
`nant melanoma. Proc Am Soc Clin Oncol 1980; 21:344.
`(7) YAGODA A, WATSON RC, BLUMENRE1CH R, YOUNG CW. Phase II trials
`in urothelial tumors with Amsa and PALA. Proc Am Soc Clin
`Oncol 1980; 21:427.
`(~q) MOYER JD, HANDSCHUMACHER RE. Selective inhibition of pyrimidine
`synthesis and depletion of nucleotide pools by N-(phosphonacetyl)-
`L-aspartate. Cancer Res 1979; 39:3089 3094.
`(9) CADMAN E, HEIMER R, DAVIS L. Enhanced 5-fluorouracil nucleotide
`formation after methotrexate: Explanation for drug synergism.
`Science 1979; 205:1135-1137.
`(10) SPIEGELMAN S, SAWYER R, NAYAK R, RtTZI E, STOLFI R, MARTIN D.
`Improving the antitumor activity of 5-fluorouracil by increasing its
`incorporation into RNA via metabolic modulation. Proc Natl Acad
`Sci USA 1980; 77:4966-4970.
`(11) JOHNSON RK, CLEMENTJJ, HOWARD WS. Treatment ofmurine tumors
`with 5-fluorouracil in combination with de novo pyrimidine inhib-
`itors PALA or pyrazofurin. Proc Am Assoc Cancer Res 1980; 21:
`292.
`(12) BUCKPITT AR, BOYD MR. A sensitive method for determination of 5-
`fluorouracil and 5-fluorodeoxyuridine in human plasma by high
`pressure liquid chromatography. Anal Biochem 1980; 106:432-437.
`(13) MACMILLAN WE, WOLBERG WH, WELLING PG. Pharmacokinetics of
`fluorouracil in humans. Cancer Res 1978; 38:3479-3482.
`(14) GRALLA RJ, KEMENY N, YOUNG CW, SYKES MP. Central nervous
`system toxicity of PALA (N-phosphonacetyl-L-aspartate). Proc Am
`Soc Clin Oncol 1980; 21:350.
`(15) COLLINS JM, DEDRICK RL, KING FG, SPEYER JL, MYERS CE. Nonlin-
`ear pharmacokinetic models for 5-fluorouracil in man: Intravenous
`and intraperitoneal routes. Clin Pharmacol Ther 1980; 28:235 246.
`(16) SPEVER JL, COLLINS JM, DEDRICK RL, et al. Phase I and pharmaco-
`logical studies of intraperitoneal 5-fluorouracil. Cancer Res 1980;
`40:567-572.
`(17) KENSLER TW, ERLICHMAN C, JAYARAM HN, TYAGI AK, ARDALAN B,
`COONEY DA. Peripheral leukocytes as indicators of the enzymic
`effect of N-(phosphonacetyl)-L-aspartic acid on human L-aspartate
`transcarbamylase activity. Cancer Treat Rep 1980; 64:967 973.
`(18) BEDIK1AN AY, VALDIVIESO M, STROEHLEIN JR, KARLIN DA, BENNET
`RW, BODEY GP. Phase I-II evaluation of PALA-5-fluorouracil
`combination in patients with colorectal carcinoma. Proc Am Soc
`Clin Oncol 1980; 21:415.
`(19) MESHAD MW, ERVIN TJ, JOHNSON RK. A phase I trial of combined
`therapy with N-(phosphonacetyl)-L-aspartate and 5-fluorouracil.
`Proc Am Soc Clin Oncol 1980; 21:341.
`
`JNCI, VOL. 68, NO. 2, FEBRUARY 1982
`
`Sandoz Inc. IPR2016-00318
`Sandoz v. Eli Lilly, Exhibit 1094-0005