Borrower: ILUUIV
`
`Lending String:
`
`Call#:
`
`Location:
`
`Patron: Burger- TN 1501562
`
`journal of the American Society of Clinical
`Oncology
`
`....J
`....J
`0 - Journal Title: Journal of clinical oncology : official
`en
`u -=
`(";l =
`...c: =
`u = ~ Volume: 17 Issue: 4
`rJJ -- Month/Year: 1999Pages: 1194-9+ TOC+acq
`·- -
`0 -c ·- -
`= - =
`- = Article Author: Rusthoven et a\.
`
`~ ~
`Article Title: Multitargeted Antifolate L Y231514 as
`0
`co
`b
`1st+ TOC+datestamp/cvr
`en
`en
`0
`""'"
`N
`.....
`10
`>
`z
`c:
`::J
`1-
`'0
`ro
`:J
`....J
`
`rJJ
`
`Imprint:
`
`ILL Number: 38232390
`I 1\\1\\ II\\ I 1\11111\\\ Ill\\ 1\Ull\111 IIIII II IIIII\
`
`ODYSSEY ENABLED
`
`Charge
`Maxcost: $15.00
`
`Shipping Address:
`UNIVERSITY OF ILLINOIS AT URBANA-
`CHAMPAIGN
`IRRC Borrowing
`104A Main Library; MC-522
`1408 W. Gregory Or.
`URBANA, IL 61801
`
`Fax: 1.217.244-1307
`Ariel:
`Email: borrowing@library.illinois.edu
`
`it'
`\
`•'l
`
`{
`
`.. NEPTUNE GJINERICS 1033- 0 001
`
`APOTEX 1033-0001
`
`

`
`Multitargeted Antifolate LY231514 as First-Line
`Chemotherapy for Patients With Advanced Non-Small-Cell
`Lung Cancer: A Phase II Study
`
`By James J. Rusthoven, Elizabeth Eisenhauer, Charles Butts, Richard Gregg, Janet Dancey, Bryn Fisher,
`and Jose Iglesias for the National Cancer Institute of Canada Clinical Trials Group
`
`Purpose: To evaluate the efficacy and safety of the
`multitargeted ontifolate LY231514 (MTA) in patients
`receiving initial chemGtherapy for unresecte~ble, ad·
`vanced non-small-cell lung cancer (NSCLC).
`Patients and Methods: Patients with measurable,ad·
`vanced NSCLC who had not received previous chemo·
`therapy for advanced disease were considered for this
`study. Eligible patients who gave written informed con·
`sent initially received MTA 600 mg/m2 introvenou51y
`(IV) for 1 0 minutes every 3 weeks. After three patients
`received treatment at this dose, the dose was reduced to
`500 mg/m2 IV at the same infusion time and frequency
`because of toxicity seen in this study and another
`Canadian MTA trial in colorectal cancer. Patients re·
`ceived up to four cycles after complete or partial remis•
`sion or six cycles after stable disease was documented.
`Results: Thirty-three patients were occrued onto the
`study. All were assessable for toxicity, and 30 potients
`were ossessable for response. All but one patient hod
`an Eastern Cooperative Oncology Group performance
`status score of 0 or 1, 18 patients (55%) had adenocarci·
`noma, and nine patients (27%) had squamous cell
`carcinoma. Twenty-five patients (76%) had stage IV
`disease, and the remainder had stage 1118 diseose at
`
`trial entry. Seven patients experienced a confirmed
`partial response and no complete responses wore seen;
`thus, the overall response rate was 23.3% (95% confi·
`den~e interval, 9.9% ta 42.3%). The median duration of
`response was 3.1 months (range, 2.3 to 13.5 monthsl
`after a median follow•up period of 7.9 months. Four
`(67%) of six patients with stage IIIB disease and three
`(12.5%) of 24 with stage IV disease responded to
`tree~tment. Four patients (13.3%) experienced febrile
`neutropenia and 13 (39"/o) experienced grodo 3 or 4
`neutropenia, whereas anly one patient (3%) developed
`grade 4 thrombocytopenio. Nonhematologic toxicity
`was generally mild or moderate, but 39% of pctionts
`developed a grade 3 skin rash. Most other toxicities
`comprised grade 1 or 2 stomatitis, diarrhea, lethargy,
`and anorexia. Ten patients stopped protocol therapy
`because of toxicity.
`Concfusion: MTA seems to have dinlcally meaningful
`activity as a single agent against advanced NSCLC.
`Toxicity is generally mild and tolerable. Further stvdyof
`this agent in combination with cisplatin and other activo
`drugs is warranted in this disease.
`J Clin Oneal 17: 1194- I 199. e 7999 by American
`Society of Clinical Oncology.
`
`THYMIDYLATE SYNTHASE (TS) is the primary tar(cid:173)
`
`get of the fluoropyrimidines fluorouracil (5-FU) and
`fluorodeoxyuridine, long-established active agents in the
`treatment of gastrointestinal cancers, breast cancer, and
`other malignancies. 1•2 Biomodulation of 5-FU by leucovo(cid:173)
`rin/ interferon? or methotrexate4 has resulted in greater
`inhibition ofTS and, consequently, improved response rates5
`and survival,6 particularly among patients with colorectal
`cancer. However, the fluorinated pyrimidines, such as 5-FU,
`
`From the Hamilton Regional Cancer Centre, Hamilton, Queen's
`University, Kingston, and Eli Lilly and Company, Scarborough, On(cid:173)
`tario; and Nova Scotia Cancer Treatment and Research Foundation and
`Dalhousie University, Halifax, Nova Scotia, Canada.
`Submitted May 18, 1998; accepted November 23. 1998.
`Supported by the National Cancer Institute of Canada Clinical Trklls
`Group, Kingston. and Eli Lilly and Company, Scarborough, Ontario,
`Canada.
`Address reprint requests to James J. Rusthoven, MD, Eli Lilly and
`Company, Lilly Research Laboratories. Lilly Corporate Center. DC
`2202, Indianapolis, IN 46285.
`@ 1999 by American Society of Clinical Oncology.
`0732-183X/9911704-J 194
`
`are indirect inhibitors ofTS, requiring metabolic activation,
`and are linked to other effects, such as alteration of RNA
`metabolism. 1 Such non-TS-inhibiting effects may lead to a
`low therapeutic index due to increased to:llicity or loss of
`efficacy. In addition, inhibition ofTS results in an increase in
`intracellular deoxyuridine monophosphate that can compete
`with pyrimidine analogs for binding to TS.11
`Direct and more specific inhibitors of TS have been
`developed that interact with the folate-binding site ofTS.'~-11
`These folate analogs have been designed to improve the
`specificity for TS inhibition; furthermore, dcoxyuridine
`monophosphate would enhance rather than competitively
`reverse their binding to TS. Multitargctcd antifolate
`LY231514 (MTA) was designed as a folate-based TS
`inhibitor with a glutamate side chain in this new class of
`folate antimetabolites. 12•13 Although MTA itself only moder(cid:173)
`ately inhibits TS, polyglutamation of the parent drug and its
`metabolites readily occurs, and the polyglutamated form of
`MTA is 100-fold more potent than MTA itself. In addition,
`other folate-requiring enzymes may act as targets for this
`drug, including dihydrofolate reductase, glycinamide ribo(cid:173)
`nucleotide fonnyltransferase, aminoimidazole carboxamide
`
`1194
`
`Journal of Clinical Oncology, Vol17, No 4 (April), 1999: pp 119.4·1199
`
`NEPTUNE GENERICS 1033-00002
`
`APOTEX 1 033 - 0002
`
`

`
`MULTI-TARGETED ANTIFOLATE FOR ADVANCED NSClC
`
`ribonucleotide formyltransferase, and C 1 tetrahydrofolate
`synthase. 14•15
`MTA has demonstrated activity in a wide range of tumor
`types. The drug is highly active against CCRF-CEM human
`leukemia cells in vitro; the activity is partially reversible
`with the addition of thymidine. 12-14 The 50% inhibitory
`concentration in CCRF-CEM cells was 7 ng/mL.n It is also
`cytotoxic in human tumorcolony-fonning unit assays against
`human colon, renal, small-cell lung and non-small-cell lung
`cancers, hepatomas, and carcinoid tumors. 16 MTA can
`inhibit tumor growth in mice transplanted with human colon
`xenografts resistant to methotrexate. 17 In beagle dogs treated
`with a weekly and/or single-dose intravenous (IV) schedule,
`major toxicities included anorexia, emesis, diarrhea, mucosi(cid:173)
`tis, weight loss, neutropenia, lymphopenia, and mild anemia.
`Plasma concentrations increased linearly with increasing
`doses, with the terminal half-life occurring at about 2.3
`hours.l8 Early studies have suggested that dietary supplemen(cid:173)
`tation with folic acid may improve the therapeutic index by
`reducing toxicity in mice.
`A phase I trial of single-agent MTA was recently com(cid:173)
`pleted in which patients were treated by 10-minute IV
`infusion every 3 weeks. Starting at 50 mg/m2, doses were
`escalated to 700 mg!m2, at which point three of six patients
`developed grade 4 neutropenia and grade 3 or 4 thrombocy(cid:173)
`topenia. In patients who received 500 to 600 mg/m2 MTA,
`serum peak concentrations were 70 to 200 !lg/mL, values
`well above the 50% inhibitory concentration in CCRF-CEM
`cells (data for peak concentrations provided by J_ Walling,
`personal communication, October 1998). Twenty patient~
`were treated at the 600-mg/in2 dose level, and 25% of them
`developed grade 4 neutropenia, 10% developed grade 3 or 4
`thrombocytopenia, and 50% developed grade 2 pruritic skin
`rash. Four partial responses (four [11%] of 37 patients) were
`seen in patients with pancreatic and colorectal cancer.19
`With these data, the recommended starting dose for phase
`ll studies using this schedule was 600 mg/m2• Two phase II
`studies have been conducted through the National Cancer
`Institute of Canada Clinical Trials Group, one in colorectal
`cancer and one in non-small-celllung cancer (NSCLC). The
`results of the latter study are reported here.
`
`PATIENTS AND METHODS
`Patient Selection
`
`Eligible patients were accrued between September 1995 and Febru(cid:173)
`ary 1997. These patients had histologically or cytologically confirmed
`inoperable, locally advanced, or metastatic NSCLC with evidence of
`bidimensionally measurable disease. Prior radiation therapy was pennit(cid:173)
`ted if acute side effects had resolved. Previous systemic therapy given
`for advanced disease was not permitted, but prior adjuvant therapy was
`allowed if the last dose was given<= 12 months earlier. Other eligibility
`criteria included (1) age <= 16 years, (2) Eastern Cooperative Oncology
`
`I
`~
`I
`
`1195
`
`Group performance status of 0 to 2, (3) serum creatinine level within
`normal limits, (4) good hepatic function (ie, serum bilirubin :s 1.5 times
`the upper normal limit and AST :s two times the upper nonnallimit or
`!f five times the upper normal limit ifliver metastases were present), (5)
`adequate bone marrow function and reserve (absolute granulocyte
`count> 1.5 X 109/L and platelet count<>: 150 X 109/L), (6) absence of
`clinically detectable third-space fluid collections, (7) absence of clinical
`evidence of brain metastases, and (8) no concurrent treatment wilh other
`experimental drugs, anticancer therapy, or folinic/folic acid supple(cid:173)
`ments.
`
`Drug Administration
`
`MTA was supplied as a lyophilized powder in 100-mg vials and was
`reconstituted by adding 10 mL of 0.9% sodium chloride. The appropri(cid:173)
`ate dose was then withdrawn, diluted in nonnal saline, and administered
`intravenously over 10 minutes every 3 weeks. Retreatment at the initial
`dose and on schedule was determined by the lack of hematologic ( :s
`grade 1 on day of treatment and granulocytopenia 2': 0.5 X 109/L and
`thrombocytopenia 2': 50 X 109/L at nadir) and nonhcmat<Jiogic (grade
`:s 2) toxicity. Patients with grade :s 2 nonhematologic toxicity were
`treated symptomatically without delays, except for cases of grade 2 skin
`rash, in which case treatment was delayed until rash improved to grade
`:s 1. Patients with severe (grade 3 or 4) nonhematologic toxicity
`received a 25% dose reduction during subsequent cycles once toxicity
`had subsided. Those with nadir granulocytopenia less than 0.5 but less
`than severe thrombocytopenia(<>: 50 X 109/L) also received a 25% dose
`reduction for the next cycle. The use of nonsteroidal anti-inflarmnatory
`drugs and salicylates was permitted but not on or around the day of
`treatment. (This precaution was taken because of previous kinetic data
`suggesting increased drug levels during coadministration of anti(cid:173)
`inflammatory agents.) Supportive-care agents, such as colony(cid:173)
`stimulating factors, were permitted but could not be substiruted for dose
`reductions required according to protocol. No dose escalations were
`permitted.
`
`Measurements of Study End Points
`
`All patients were assessable for toxicity from the time of their first
`treatment_ Patients who had received at least one cycle of MTA and had
`follow-up measurements performed to assess change in tumor size were
`assessable for response. Response was assessed on day 1 of each cycle
`by clinical tumor measurements and documentation of the tumor size of
`measurable and uonmeasurable disease, using positive mdiographic
`tests. If results were initially negative, tests were repeated only if
`clinically indicated. All sites with measurable lesions were followed for
`response. Measurements of undimensional lesions (ie, single largest
`dimensions) and bidimensional lesions (the products of the largest
`diameter and its largest perpendicular) were summed at each assessment
`and the best response on study was recorded.
`A complete response required the disappearance of all clinical and
`radiologic evidence of tumor for at least 4 weeks. A partial response
`required a 2': 50% decrease in the sum of the products of the diameters
`of all measurable lesions, also for at least 4 weeks. Stable disease
`designated a steady-state of disease, which was a response less than a
`partial response or progression less than progressive disease, both for at
`least 6 weeks from the start of therapy. In addition, there could be no
`new lesions or increases in the size of any nonmeasurable lesions for
`
`NEPTUNE GENERICS 1033 - 00003
`
`APOTEX 1 033 - 0003
`
`

`
`1196
`
`complete or partial remissions or for stable disease. Progressive disease
`indicated an unequivocal increase of at least 25% in the sum of the
`products of the diameters of all measurable lesions compared with
`baseline or the appearance of new lesions. Nonmeasurable disease was
`not considered in the response assessment, except that new lesions
`would constitute progressive disease; all nonmeasurable lesions had to
`disappear for a designation of complete response to be made.
`Response duration was defined from the time that criteria for
`response were met until disease progression was objectively docu(cid:173)
`mented, with disease progression measured from the time that response
`was established. Stable disease was measured from the start of therapy
`until disease progression. All reported responses were verified by
`independent radiology review.
`
`RESULTS
`Thirty-three patients were accrued onto this study. All
`patients were assessable for toxicity, and 30 patients were
`assessable for response. The three unassessable patients
`came off study before the second treatment because of
`toxicity. One hundred thirty-two cycles were administered;
`13 cycles were given to the three patients at the initial
`600-mg!m2 dose (median, six cycles; range, one to six
`cycles), and 75 cycles were given to patients who started at
`the 500-mg/m2 dose (median, four cycles; range, one to
`eight cycles). Of the 30 patients who started at the 500-
`mg/m2 dose, 15 received one cycle at this dose, four received
`two cycles, and 11 received three or more cycles. Fourteen
`patients required a dose reduction to 375 mg/m2 for one or
`more cycles. Four patients required a further dose reduction
`to 281 mg/m2• Characteristics of the 33 patients are listed in
`Table 1. The majority were male, presented with excellent
`performance status, and received only radiotherapy as prior
`treatment. A majority (18 of 33) had adenocarcinoma as a
`histologic diagnosis, and 26 of 33 patients had more than
`one site of involvement at study entry. At the time this article
`was written, the median follow-up was 7.9 months (range,
`3.3 to 16.8 months). (For patients who died, the last
`follow-up date was the date of death.)
`
`Antitumor Activity
`Of the 30 patients assessable for response, none had a
`complete response and seven patients had a confirmed
`partial response; thus, the overall response rate was 23.3%
`(95% confidence interval, 9.9% to 42.3%). When all eligible
`patients are included, the response rate is 21.2%. The
`median time to progression for all patients was 3.8 months
`(range, 0.5 to 15.8 months). The median survival time of all
`patients was 9.2 months (Fig 1), and the 1-year survival rate
`was 25.3% (95% confidence interval, 9.7% to 40.9%). A
`higher response was seen among stage IIIB patients (four
`[67%] of six) compared with those who entered the study
`with stage IV disease (three [12.5%] of 24).
`
`RUSTHOVEN ET AL
`
`Table 1. Patient Characteristics
`
`No. oiPoti"'b
`
`63
`.42-7.4
`
`Age, year>
`Median
`Range
`Sex
`Female
`Male
`Performance stows•
`0
`1
`2
`Histology
`Adenocarcinoma
`Squamous
`Undifferential
`Prior therapy
`Radiation therapy
`Sites of disease
`Lung
`Lymph nodes
`Liver
`Bone
`Adrenal
`Pleural effusion
`Subcutaneous
`Spleen
`Stage at srudy entry
`IIIB
`IV
`No. of organ sites involved
`1
`2
`3
`;,A
`
`7
`26
`
`13
`19
`
`18
`9
`6
`
`11
`
`27
`24
`8
`7
`7
`5
`1
`
`8
`25
`
`7
`11
`10
`5
`
`"Eastern Coopoerctive Oncology Group performance status.
`
`Toxicity
`
`After the first three patients were accrued, a decision was
`made to reduce the starting dose to 500 mg/m2 based on the
`combined toxicity of 12 patients entered onto this study and
`a Canadian study of the same initial dose and schedule in
`patients with advanced colorectal cancer (Cripps et al,
`manuscript submitted for publication). Of the first three
`patients in the present trial, one patient experienced grade 3
`dyspnea, mucositis, and high fever with radiographic suspi(cid:173)
`cion of pneumonia. The patient recovered but refused further
`therapy. The other two patients completed six cycles of
`therapy at the initial dose. 1\vo of the three patients
`experienced grade 3 neutropenia, and none experienced
`higher than grade 2 renal or hepatic toxicity. The hemato(cid:173)
`logic toxicity experienced by the 30 patients who started at
`the 500-mg/m2 dose level was similar to that of the other
`three patients. Hematologic toxicity, as median nadir counts
`and by worst grade experienced for all patients, is listed in
`Table 2. Overall, only two patients experienced a grade 4
`
`NEPTUNE GENERICS 1033- 00004
`
`APOTEX 1 033 - 0004
`
`

`
`MVLHARGETED ANTIFOtATE FOR ADVANCED NSCLC
`
`1197
`
`Table 3. Nonhematologic Toxicity (n = 33)
`Grado {no. of patient>)
`
`Toxicity
`
`Skin rash
`Lethargy
`Anorexia
`Diarrhea
`Nausea
`Arthralgia
`Stomatitis
`Vomiting
`Tearing
`Edema
`Febrile neutropenia
`Infection
`
`1
`
`2
`3 10
`5
`15
`8
`10
`9
`2
`13
`9
`1
`4
`4
`5
`8
`5
`6
`3
`5
`5
`
`3
`
`3
`
`4
`
`3
`13
`0
`0
`9
`A 0
`3 0
`A 0
`3 0
`0
`2
`3 0
`2
`0
`3 0
`4
`4
`
`0
`
`Total No. of %of
`%Drug-
`Patients RelatodOnly
`Patients
`
`26
`29
`22
`14
`26
`8
`11
`16
`11
`13
`4
`10
`
`79
`88
`67
`42
`79
`24
`33
`49
`33
`39
`12
`30
`
`79
`76
`58
`33
`76
`0
`33
`46
`30
`21
`12
`6
`
`DISCUSSION
`Initial results from preclinical animal studies and phase I
`trials suggested clinical activity for MTA primarily against
`colorectal and pancreatic cancer.19•20 The level of activity
`seen in the present study in NSCLC was higher than initially
`anticipated, and independent reviewers confirmed all re(cid:173)
`sponses. This promising level of clinical activity was seen in
`patients with lung and lymph node involvement as well as in
`those with visceral and bone involvement, although the
`proportion of patients who responded was much higher in
`the group of stage lliB patients. In another phase ll study of
`MTA in patients with NSCLC by Clarke et al,21 all patients
`were initially treated with 600 mg/m2 MTA. Response rates
`were comparable to those in this study; among 12 patients
`assessable for response, the overall response rate was 33%
`(all partial responses). Toxicity profiles were similar be(cid:173)
`tween the two studies; in addition, toxicity seen in the phase
`I studies was similar to that reported for other drugs in this
`class.19
`0.22 Neutropenia was the predominant hematologic
`toxicity, resulting in dose reduction in 12% of patients, but it
`did not lead to treatment delays; only one patient (3%)
`experienced dose-reducing (grade 4) thrombocytopenia.
`Most symptomatic, nonhematologic toxicity was man(cid:173)
`aged with appropriate supportive care; for ;:: grade 3
`toxicity, the next cycle was delayed until symptoms resolved
`to 2': grade 1 severity and subsequent doses were reduced by
`25%. Nausea and emesis were infrequent and not severe,
`
`•2
`
`Table 4. Biochemical Changes (n "' 311
`
`o.a
`
`0.4
`
`~ 0.6
`c
`i
`~ " Ill
`<
`0 t
`0 .. 2 0.2
`..
`
`0
`0
`33
`
`Median survlval: 9.51 months
`
`5
`30
`
`10
`16
`Time (months)
`#At Risk
`
`15
`
`20
`
`Fig I. Overall survival of oil patients.
`
`adverse event; one experienced a cerebrovascular accident,
`and the other patient developed a deep vein thrombosis and
`pulmonary thromboembolus associated with severe short(cid:173)
`ness of breath. Neither of these events was considered
`related to the MTA therapy. Other than these cases, the most
`severe and prevalent nonhematologic toxicities are listed in
`Table 3. Severe (grade 3) nonhematologic toxicity presented
`most commonly as a skin rash (39% ), lethargy (27% ),
`anorexia (12%), nausea (12%), vomiting (9%), and diarrhea
`(9%), most of which was attributable to the study drug. The
`skin rash was generalized in half of affected patients and
`symptomatic with primarily pruritus in 23 of 26 patients.
`Subsequent retrospective analysis in this and the colorectal
`phase TI smdy of the same agent showed that patients who
`received dexamethasone in their first cycle had a lower
`frequency and severity of skin rash (without dexamethasone,
`93% of cycles with skin rash, 47.5% grade 3; with dexametha(cid:173)
`sone, 56% of cycles with skin rash, 12% grade 3). Four
`patients (12% of all patients) on the study developed febrile
`neutropenia, with one documented severe systemic infection
`considered related to protocol therapy.
`Nonhematologic biochemical changes were mild. Only
`three patients developed transient grade 3 elevations of their
`liver function tests (bilirubin and AST), and only one patient
`developed grade 2 elevation of serum creatinine (Table 4).
`
`Table 2. Hematologic Toxicily (n = 331
`Nodir (X 10'/l\
`Toxicily Grado
`Median
`
`Ronge
`
`0
`
`HemCIJiobin, g/l
`WBC
`Gronulocyies
`Pbtelets
`
`111
`2.5
`1.1
`152
`
`73-149
`0.4·8.1
`0.0-4.0
`20·278
`
`6
`6
`7
`17
`
`14
`5
`3
`14
`
`10
`9
`10
`
`3
`11
`9
`0
`
`4
`
`Test
`
`0
`2
`4
`
`Serum creatinine
`Bilirubin
`AST
`Alkaline phosphatase
`
`0
`29
`26
`5
`14
`
`Toxicity Grade
`
`3
`
`4
`
`0
`17
`16
`
`1
`4
`7
`1
`
`0
`
`2
`0
`
`0
`0
`0
`0
`NEPTUNE GENERICS 1033-00005
`
`APOTEX 1 033 - 0005
`
`

`
`1198
`
`and physician discretion was permitted for prophylaxis
`based on the low emetogenic potential projected from phase
`I studies. Skin rashes were frequent; 30% of patients had
`treatment delayed with no subsequent dose reduction,
`whereas patients with generalized, symptomatic rash (39%)
`were given a 25% dose reduction. Both groups were treated
`prophylactically with dexamethasone for 3 days starting the
`day before each subsequent dose. With this intervention,
`skin toxicity decreased in subsequent cycles. Later in the
`study, it was noted that prophylactic dexamethasone given in
`cycle 1 seemed to have a beneficial effect in reducing the
`expected frequency and severity of skin rash. Future trials
`should likely incorporate this premedication at the first dose.
`Thirty percent of patients came off protocol therapy because
`of toxicity, most often gastrointestinal This highlights the
`considerable interpatient variability of the toxicity experi(cid:173)
`enced. Nonhematologic biochemical alteration of renal and
`hepatic function was relatively mild and of no clinical
`consequence. In three patients (9% ), grade 3 elevation of
`bilirubin or AST levels resulted in dose reduction.
`The decision to reduce the starting dose from 600 mg/m2
`to 500 mg/m2 early in this study was based largely on the
`toxicity seen in a larger cohort of patients in a Canadian
`phase II study of colorectal cancer that is using the same
`dose and schedule. The toxicity seen in all other phase II
`trials of lung, breast, and gastrointestinal tumors at the
`600-mglm2 dose and schedule has been similar to that seen
`in our study. Factors that may be associated with the more
`severe toxicity seen in the Canadian colorectal trial cohort
`have not yet been identified. The clinical activity in our trial
`
`RUSTHOVEN ET AL
`
`is similar to that seen in the study of Clarke et al,21 in which
`all patients started at a dose of 600 mg/m2• Furthennore, it is
`interesting that all responding patients were treated at an
`initial dose of 500 mg/m2•
`MTA clearly has relevant clinical activity in patients with
`advanced NSCLC and toxicity that is tolerable with conven(cid:173)
`tional dose and schedule adjustments. In addition to its effect
`on multiple enzymes in the folate-dependent pathways,
`MTA can synchronize treated cells at the Gt/S interface
`initially, followed by synchronous entry of treated cells into
`S phase II 4 hours after initial drug exposure in vitro.23 A
`recent study suggests that MTA may enhance the cytotoxic
`effect of other drugs, such as gemcitabine, when target
`cancer cells are exposed to MTA 12 to 24 hours earlier.24 A
`phase I combination trial of these two agents is in progress.
`As a result, further studies are planned to test the efficacy of
`MTA in combination with other agents with proven efficacy
`against NSCLC, such as the taxanes and platinum com(cid:173)
`pounds. Our group is presently conducting a phase II
`combination study of MTA and cisplatin in advanced
`NSCLC. Ultimately, it is hoped that MTA may contribute to
`an improvement in the survival and quality of life of some
`patients with this disease.
`
`ACKNOWLEDGMENT
`We thank the following investigators who, in addition to the authors,
`contributed patients to this study: Y. Cannier, Hopital Laval. Quebec
`City; A. Neville, Hamilton Regional Cancer Centre, Hamilton; and F.
`Shepherd, The Toronto Hospital, Toronto, Canada.
`
`REFERENCES
`1. Rustum YM, Harstrick A, Cao S, et a!: Thymidylate synthase
`7. Harrap KR, Jackman AL, Newell DR, et a!: Thymidylate syn(cid:173)
`thase: A target for anti-cancer drug design. Adv Enzyme Regul
`inhibitors in cancer therapy: Direct and indirect inhibitors. J Clin Oneal
`29:161-179. 1989
`15:389-400,1997
`2. Poon MA, O'Connell MJ, Moertel CG, et a!; Biochemical
`8. Spears CP, Gustavsson BG, Verne M, et al: Mechanisms of innate
`resistance to thymidylate synthase inhibition after 5-fluorouracil. Can(cid:173)
`modulation of fluorouracil: Evidence of significant improvement of
`cer Res 48:5894-5900, 1988
`survival and quality of life in patient~ with advanced colorectal ·
`9. Jackman AL, Calvert AH: Folate-based thymidylate synthase
`carcinoma. J Clin Oneal 7:1407-1418, 1989
`3. Sotos AG, Grogan L, Allegra CJ: Preclinical and clinical aspects
`inhibitors as cancer drugs. Ann Onco16:871-881, 1995
`ofbiomodulation of 5-fluorouracil. Cancer Treat Rev 20:11-49, 1994
`I 0. Taylor EC: Design and synthesis of inhibitors of folate-depended
`4. The Advanced Colorectal Cancer Meta-Analysis Project: Meta(cid:173)
`enzymes as anti-tumour agents. Adv Exp Med Bioi 338:387-408, 1993
`analysis of randomized trials testing the biochemical modulation of
`II. Touroutoglou N, Pazdur R: Thymidylate synthase inhibitors.
`fluorouracil by methotrexate in metastatic colorectal cancer. J Clin
`Clin Cancer Res 2:227-243, 1996
`Oncoll2:960-969, 1994
`12. Shih C, Grindey GB, Barnett CJ, et al: Structure-activity
`5. The Advanced Colorectal Cancer Meta-Analysis Project: Modula(cid:173)
`relationship srudies of novel pyrrolopyrimidine anti-folate LY231514.
`Proc Am Assoc Cancer Res 33:411, 1992 (abstr 2452)
`tion of fluorouracil by leucovorin in patients with advanced colorectal
`cancer: Evidence in terms of response rate. J Clin Oncol 10:896-903,
`13. Grimley GB, Shih C, Barnett CJ, et al; LY231514, a novel
`pyrrolopyrimidine anti-folate that inhibits thymidylate synthase (TS).
`1992
`6. Scheithauer W. Depisch D, Kornek G, eta!: Randomized compari(cid:173)
`ProcAmAssoc Cancer Res 33:411, 1992 (abstr2451)
`son of fluorouracil and leucovorin therapy versus fluorouracil, leucovo(cid:173)
`14. Shih C. Chen VJ, Gossett LS, eta!: LY231514, a pyrrolo [2,3-d]
`rin and cisplatinum therapy in patients with advanced colorectal cancer.
`pyrimidine-based antifolate that inhibits multiple folate-requiring en(cid:173)
`Canccr73:1562-1568, 1994
`zymes. Cancer Res 57:1116-1123, 1997
`
`NEPTUNE GENERICS 1033-00006
`
`APOTEX 1 033 - 0006
`
`

`
`MUlTI-TARGETED ANllFOLATE FOR ADVANCED NSCLC
`
`1199
`
`15. Chen VJ, Bewley JR, Gossett L, et al: Activity of LY231514
`against several enzymes in the folate-dependent pathways. Proc Am
`;,ssocCancerRes 37:381, 1996 (abstr2598)
`16. Von Hoff DD: Human tumour cloning assays: Applications in
`clinical oncology and new anti-neoplastic agent development. Cancer
`Metastasis Rev 7:357-371, 1988
`17. Schultz RM,Andis SL, Bewley JR. eta!: Antirumor activity of
`the multi-targeted anti-folate LY2315!4. Proc Am Assoc Cancer Res
`37:380, 1996 (abstr2597)
`18. Tbymidylate synthase inhibitor LY231514 [clinical investigation
`brochure].lndianapo!is, IN, Lilly Research Laboratories, Eli Lilly and
`Co, 1992
`19. Rinaldi D, Burris H, Dorr F, et a!: A phase I evaluation of
`LY231514 administered every 21 days, utilizing the modified continual
`reassessment method for dose escalation. Proc Am Soc Clin Oncol
`14:474, 1995 (abstr 1539)
`20. Rinaldi D, Burris, Dorr F, et a!: Initial phase 1 evaluation of the
`novel thymidylate synthase inhibitor, LY231514, using the modified
`
`continual reassessment method for dose escalation. J Clin Oneal
`13:2842-2850, 1995
`21. Clarke S, Boyer M, Milward M, et a!. Phase II srudy of
`LY231514, a multi-targeted antifolate, in patients with advanced
`non-small cell lung cancer (NSCLC). Proc Am Soc Clin Oncoll6:465a,
`1997 (abstr 1670)
`22. Zalcberg JR, Cunningham D, Van Cutsem E, eta!: ZD1694: A
`novel thymidylate synthase inhibitor with substantial activity in the
`treatment of patients with advanced colorectal cancer. J Clin Oneal
`14:716-721, 1996
`23. 'Ibnkinson JL, Marder P, Andis SL, et al: Cell cycle effects of
`anti-folate antimetabolites: Implications for cytotoxicity and cytostasis.
`Cancer ChemotherPhannaco139:521-531, 1997
`24. Tonkinson JL, Wagner MM, Paul DC, et al: Cell cycle modula(cid:173)
`tion by the multi-targeted anti-folate, LY231514, increases the antipro·
`liferative activity of gemcitabine. Proc Am Assoc Cancer Res 37:370,
`1996 (abstr 2523)
`
`NEPTUNE GENERICS 1033-00007
`
`APOTEX 1 033 - 0007
`
`

`
`*§I(ImI
`
` .;';..:itL»:
`1:'5E5‘.':‘fifi'
`
`
`
`‘kwmy:1,:,.-'3
`
`
`
`NEPTUNE GENERICS 1033- 00008
`
`;'I
`.
`I
`III:
`APOTEX 1 033 - 0008
`
`

`
`“ pffi’, .: ‘
`/V
`_
`NEPTUE ENERIC 1033 — 00009
`NEPTUNE GENERICS 1033-00009
`
`APOTEX 1 033 - 0009
`APOTEX 1033 - 0009
`
`

`
`Journal of Clinical Oncology
`
`The Official Journal of the American Society of Clinical Oncology
`
`Vo117, No 4
`
`April1999
`
`CONTENTS
`
`EDITORIAL: Signaling Inhibitors in the Clinic: New Agents and New Challenges ............................ Gary Hudes
`
`1093
`
`Clinical Pharmacology and Pharmacokinetics
`
`ORIGINAL REPORTS
`
`Phase I and Pharmacologic Study of the Tyrosine Kinase Inhibitor SU101 in Patients With Advanced Solid
`Tumors ................................. S. Gail Eckhardt, Jinee Rizzo, Kevin R. Sweeney, Gillian Cropp, Sharyn D. Baker,
`Maura A. Kraynak, John G. Kuhn, Miguel A. Villalona-Calero, Lisa Hammond, Geoffrey Weiss, Allison Thurman,
`Lon Smith, Ronald Drengler, John R. Eckardt, Judy Moczygemba, Alison L. Hannah, Daniel D. Von Hoff,
`and EricK. Rowinsky
`
`1095
`
`Gastrointestinal Oncology
`
`Correlation Between Uracil and Dihydrouracil Plasma Ratio, Fluorouracil (5-FU) Pharmacokinetic
`Parameters, and Tolerance in Patients With Advanced Colorectal Cancer: A Potential Interest for
`Predicting 5-FUToxicity and Determining Optimal5-FU Dosage ................ E. Gamelin, M. Bvisdron-Celle,
`V. Guerin-Meyer, R. Delva, A. Lortholary, F Genevieve, F. Larra, N. lfrah, and J. Robert 1105
`
`Efficacy and Safety of Prolonged-Release Lanreotide in Patients With Gastrointestinal Neuroendocrine
`Thmors and Hormone-Related Symptoms .......... A.N.M. ll)!menga, B. Eriksson, P.I. Salmela, M.B. Jacobsen,
`E.J.D. G. Van Cuts em, R.H. Fiasse, M.J. Vdlimiiki, J. Renstntp, E. G. E. de Vries, and K.E. Oberg
`
`1111
`
`Breast Cancer
`
`5-Year Results of Dose-Intensive Sequential Adjuvant Chemotherapy for Women With High-Risk
`Node-Positive Breast Cancer: A Phase II Study .......... C. Hudis, M. Fomier, L. Riccio, D. Lebwohl, J. Crown,
`T. Gilewski, A Surbone, V. Currie, A. Seidman, B. Reichman, M. Moynahan, G. Raptis, N. Sklarin, M. Theodoulou,
`L. Weiselberg, R. Salvaggio, K.S. Panageas, T.J. Yao, and L. Norton
`
`Ducetaxel: Standard Recommended Dose of 100 mg/m2 Is Effective But Not Feasible for Some Metastatic
`Breast Cancer Patients Heavily Pretreated With Chemotherapy-A Phase II Single-Center Study
`E. Salminen, M. Bergm