Preliminary Results of a Phase i Study With MTA (LY231514) in
`Combination With Cisplatin in Patients With Solid Tumors
`
`Rail Th6dtmann, Henrik Depenbrock, Johannes BIatter, Robert D. Johnson, Allan van Oosterom, and Axel-R. Hanauske
`
`HTA (multltargeted antifolate, LY231514) is a novel
`antimetabolite resulting from structure/activity studies
`at’the Iometrexol-type antlfolates. It has been shown to
`Inhlblt various enzymes of relate pathways and has
`broad antltumor acttvlty in a variety of In vitro and in
`vlvo tumor models. Clinical phase I studies have been
`performed using different administration schedules,
`and subsequently the every-21-days schedule has been
`selected for further development. We report the pre-
`liminary findings from a combination phase I study of
`NTA and cisplatin admlnlstered every 21 days. In the
`first cohort (34 patients), both agents were adminis-
`tered on day I with a starting dose of 300 mg/m2 PITA
`and 60 mg/mz cisplatin. In a second cohort (10 pa-
`tients), HTA (500 or 600 mglmz) was administered on
`day I followed by dspfatin (75 mg/m2) on day 2. The
`maximum tolerated doses were reached at 600 mg/m~
`MTA~I00 mg/m~ cisplatin (cohort I) and 600 mglmz
`HTAI75 mg/mz cisplat~n (cohort 2). In cohort I, dose-
`limiting toxlcittes consisted of reversible myelosup-
`presslon with leukopen]a and neutropenla. In addition,
`delayed fatigue also was of clinical significance. Phar.
`macoklnetlc analyses indicated that hydration admin-
`Istered before the administration of cisptatln did not
`Influence the major pharmacokineUc parameters of
`HTA. Eleven objective remissions were observed, In-
`cluding one complete response in a patient with re-
`lapsed squamous cell carcinoma of the head and neck
`and partial responses in four of seven patients with
`mesothelioma. In contrast, the dose.limltlng toxtcltles
`In patient cohort 2 consisted of neutropentc sepsis,
`diarrhea, and skin toxicity wlth two possibly treatment-
`related deaths on study, No objective remissions are
`presently observed In cohort 2. We conclude that the
`combination of HTA and clsplatln Is feasible and clini-
`cally active when both agents are administered on day
`I and that it should be pursued for further clinical
`development,
`Semln Oncol 26 (suppl 6):89-93. Copyright © 1999 by
`W,B. Saunders Company.
`
`M TA (multitargeted antifolate, LY231514,
`
`N-[4-[2-(2-amino-3,4-dihydro-4-oxo-TH-
`pyrrolo[2,3-d]pyrimidin-5-yl)ethyl]-benzoyll-L-
`glutamic acid) is a novel antimetabo[ite resulting
`from structure/activity studies of the Iometrexol-
`type antffolates.~,z After ce[ltdar uptake, the com-
`pound undergoes polyglutamation with production
`of predominantly triglutamates and pentagluta.
`mates) MTA, as well as its polyglutamates, has
`been shown to inhibit various enzymes of the
`folate pathways, including thymidylate synthase,
`dihydrofolate reductase, glycinamide ribonucle-
`
`otide formyltransferase, and aminoimidazole car-
`boxamide ribonucleotide formyhransferase,x The
`compound arrests CCRF-CEM cells at the GI/S
`transition and has Been shown to induce apoptosis
`in these cetls.~ MTA has broad antitumor activity
`in a variety of in vitro tumor models and is active
`against lymphoma, colon, lung, pancreas, and
`breast cancer xenografts in viva.~ The precfinical
`toxicology studies demonstrated that nutritional
`folate supplementation decreased toxicity of the
`compound while enhancing its activity.~
`Clinical phase t studies have been performed
`using three different administration schedules (ev-
`ery 21 days, daily ×5 every 3 weeks, weekly ×4
`every 6 weeks),6~ Based on the toxicity profile, the
`ability to give repeat doses, and the ease of admin-
`istration, the every-21.days schedule was subse-
`quently selected for further development of MTA
`in clinical phase I1 studies. At present, several
`single-agent phase 11 studies are in progress or
`under analysis and MTA appears to be active in
`the colon, pancreas, and breast cancer. We report
`here the preliminary results of a phase 1 combina-
`tion study of" MTA and cisplatin.
`
`PATIENTS AND I~IETHODS
`
`The objectives of the study were to determine the maximum
`tolerated dose and the dose-limiting toxicity (DLT) of MTA
`when combined with cisplatin, to recommend a safe and fea-
`sible dose and schedule for subsequent phase [l studies, and to
`collect anecdotal information on the antitumor activity of this
`
`From the Universitair 7.i&enhuis Gasthtiisberg, Ka~hdic Unh,er-
`sky of Leuven, Bel~mn; ~he Eli Litly Compaay, Bad Homburg,
`Gen~mny; and LiIty Research Labom~offe~, Eli Lilly aM Company,
`hutian@olis, IN.
`Spomored by Eli l~tly and Compa,,y.
`Dr Tied,harm ~ received honorarium from Eli gitly mtd
`Compa~,y, Drs Bla~er and Johnaon are employees of Eli Lilly a~ut
`Company. Dr Hanauske is a co~sultant for Eli Lilly and Company
`and tlex Oncobg,j; has received honoraria from Eli Lilly a~ut
`Company, Yewlree, Nycomed, and l~ex Onco~g’,j; has receit,ed
`research support from Eli Lilly and Company, SmithKtine Beeclu~m,
`Asta Medical, Rhbne.Pmdenc Rarer, and Esai, a~ut is a pra*.q~bar of
`expert tes6mony for RhSne:Pot&nc Rarer.
`Address reprim requesu to Axel.R. t tanauske, biD, PhD, Cem
`ter for Hematology a~d Oncolog),, Landwehr~tr 2, /)-80336
`MRnehen, Germany.
`Copyr~! © I999 by W.B. Saunders Company
`0093-7754f99f2602<~6 t45 t0.00/0
`
`,Sera~aats in OncoloD’, Vol 26, i~o 2, Suppl 6 (April), 1999; pp B9.93
`
`89
`
`Sandoz Inc.
`Exhibit 1017-0001
`
`JOINT 1017-0001
`
`

`
`90
`
`TH(~DTHANN ET AL
`
`corubination, tn addition, characterization of pharmacokinetic
`parameters of MTA and cisptatln were planned at higher doses
`of the combination.
`Major eligibility criteria included histotogic or cytologic di-
`agnosis of cancer for which no proven therapeutic option was
`available, World Health Organization perfor,nunce status
`estimated life expectancy of ~12 weeks, granul~cytes >--1.5 ×
`109/[., white blood cell count .>-3.0 × 109/L, platelets ->1(30 ×
`109]L, hemoglobin >--9.0 E/L, serum bilirubin cortcenttation
`-<1.5 mg/dL, alanlne transaminase or aspattate tmnsaminase
`~3 times upper ,arms[ value (~:5 times normal in case o(
`disease metastatic to the liver), prothrombin time and partial
`thromboplastin time within normal range, creatinine -<l.5
`mg,/dL or calculated creatinine clearance >60 mgJmin, and
`written informed consent. Exclusion crlterla included diagnosis
`of hematologic mahgnancy, platinum therapy whhin 6 months
`before study entry, chemotherapy within 3 weeks before study
`onto/(6 weeks in case of nitrosoureas or mitomycin C), clinical
`evidence for brain metastasis, active heart disease, myocardial
`infarction within 6 months before study entry, childbearing
`potential without adequate contraception, pregnancy, breast
`feeding, active infection, and serum calcium concentration
`above upper limit.
`Two treatment schedules were studied. In cohort 1, patients
`received MTA as ~o intravenous tofl~slon over 10 minutes after
`prehydration whh ~ L of normal saline. Thirty minutes after
`the end of the MTA infusion’, cisplatin was administered over
`2 hours together with 150 ml. of mannhol. Patients were
`subsequently posthydrated with 2 L of normal saline ~nd glu-
`cose and appropriate substitution with potassium chloride, so.
`dium bicarbonate, and magnesium. An antiemetic regimen was
`administered intravenously before the infusion of MTA and
`consisted of dexamethasone (8 mg), granisetron (5 rag), and
`ali~apride (50 rag). The starting doses were MTA 300 mgJm~
`and c[splatin 60 mg/m~, In cohort 2, patients received MTA
`without hydration or antiemetic medication on day 1. This was
`followed by prehydvation, clsptatin administration, and posthy-
`dration on day 2. The hydration schedules and antiemetic
`regimen were identical in both patient cohorts. The starting
`doses for patient cohort 2 were MTA 500 mg!mz and cispIatin
`75 mg/m2.
`Toxieities were graded according to the Natlot~a[ Cancer
`institute Common Toxicity CriteriaY Dose-limiting toxicities
`were defined as follows: grade 4 neutropenta lasting longer than
`5 days, febrile neuttopenia, grade 4 thrombocytopenia, and
`grade >-3 nonhematologic toxicity (except for a[opecia or
`inadequately treated nansen or vomiting). The maximum tol-
`erated dose was defined as the dose level at which two or more
`of slx patients developed a DLT. At each dose level, a mint.
`mum of three patients were entered. Three additional patients
`were entered if toxicities one grade below the DLT were
`observed in at least one of the initial patients. Patients expe-
`riencing DLTs were taken off study unless a benefit from the
`therapy could be demonstrated. In this case, treatment was
`continued at a lower dose at the discretion of ~e investigator.
`While the determination of tumor response wa~ not a prio
`mary objective of this phase [ study, tumor measurements were
`recorded and response status was assigned according to standard
`World Health Organization criteria.I°
`For pharmacokinetic analyses, blcrod samples were taken at
`higher dose levels during the first cycle after the administration
`
`of MTA and cisplatin, and urine was collected for up to ’18
`hours after the end of the MTA infusion. A liquid chromatogo
`raphy mass spectrometry assay was used for determination of
`MTA concentrations as described earlier.6
`
`RESULTS
`
`Forty-four patients were entered into this phase
`I study. Of these, 34 patients were entered (with
`33 evatuable for response) into cohort t and 10
`patients were entered into cohort 2. Of the pa-
`tients entered into cohort 1, 29 were men ond five
`were women. The age range was 41 to 72 years and
`the median performance status was 1 (range, 0 to
`2). Sixteen and nine patients had received prior
`chemotherapy or radiotherapy, respectively. The
`remaining nine patients were chemotherapy-n~-
`ive. Doses of MTA ~nd cisplatin were increased
`stepwise to 600 mgjm~ MTA and 75 mg/m2 cis-
`platin with three to seven patients entered at each
`dose level. As summarized in Table 1, the most
`common tumor types were mesothelioma, head
`and neck cancer, and non,small cell lung cancer.
`Table 2 summarizes the hematologic toxicity
`seen at each dose level. When administered in
`combination with cisp[atin on day 1, the DLT of
`MTA was myelosuppression, consisting predomi-
`nantly of leukopeni~ nod neutropenim Doseolim-
`iting toxicities were t~ot seen exclusively during
`course one in all patients, but occasionally were
`delayed until further cycles were administered.
`However, we have seen no evidence for reproduc-
`ible cumulative bone marrow toxicity. When the
`first cycle was used exclusively to deflate maximum
`tolerated dose, it was found to be 600 mg/m2 MTA
`and 100 mg/m2 cisplatin. If all cycles were evalu-
`ated, the maximum tolerated dose was 600 mg!m2
`
`Table I, Tumor Type Dlstrlbutlon
`
`Tumor Type
`
`H eso~.hdioma
`Head and ned<
`Non~sma[~ cell
`Colorectal
`Esophagus
`Hepatocellular
`Helanoma
`Unknown p~ma~
`Small ~ell lung
`
`No. ol Patients
`
`7
`7
`
`S
`
`3
`3
`2
`2
`
`2
`I
`I
`I
`
`Sandoz Inc.
`Exhibit 1017-0002
`
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`
`

`
`PHASE I STUDY VVITH I’YI’A AND CISPLATIN
`
`91
`
`Anemia
`
`Thrombo~3"topenl~
`
`0
`
`|
`o
`I
`I
`
`0
`0
`
`0
`I
`
`3
`
`0
`3
`0
`I
`0
`I
`
`4
`
`0
`I
`0
`0
`o
`|
`
`*Both agents were administered on day I of each course.
`| National Cancer institute Common Toxldty. Crfteda grades.
`
`MTA and 75 mg./mz cisplatin. Nonhematologic
`toxicities are summarized in Table 3. Due to the
`extensive premedication for the prevention of ciso
`platin-induced emesis, nausea and vomiting were
`mostly mild to moderate. While diarrhea was
`served occasionally at higher doses, it did not
`cause clinical complications. Similarly, mild to
`moderate mucositis was occasionally observed.
`The treatmentAnduced myelosuppression was not
`complicated by higher-grade infections. However,
`a delayed occurrence of fatigue was notable at high
`doses of MTA.
`Several objective antitumor responses were obo
`served in patient cohort 1 and are listed in Table
`4. Clinical antitumor activity of MTA/cisplatin
`was notable throughout all dose levels, Most
`portantly, one patient with a relapsed squamous
`cell carcinoma of the head and neck developed a
`
`complete, although short-lasting, response. In ad-
`dition, four of seven patients with mesothelioma
`developed a partial remission. Each of these four
`mesothelioma responses has been confirnaed by an
`independent reviewer with a specialty in radiol-
`o~. This reviewer verified that three of the four
`patients had lesions that were bidimensionalty
`measurable and one patient had unidimcnsionally
`measurable thickening of the pleura.
`A preliminary analysis of pharmacokinetic pa-
`rameters indicates that the plasma half-life of
`MTA is approximately 3.2 hours, which corre-
`sponds to the published half-life after single.agent
`therapy.
`Because MTA is renal|y excreted, it may be
`hypothesized that the prehydration with cisplatin
`administration might influence the clearance of
`MTA and modifi/the pattern of toxicity or anti-
`
`30~/,60
`(N - 6)
`
`~oorts
`(N~7)
`
`400as
`(N = 6)
`
`soons
`(N =3)
`
`t~o~s
`(N= 6)
`
`600n 00
`(N:6)
`
`Dose l"ffA/Clsplatln (mg/m~
`
`Toxicity Type
`
`Nausea
`Vomiting
`Dlarrl~ez
`~lucoslds
`InfectJon
`Fa6g~e
`Anorexia
`
`2
`
`t
`0
`I
`0
`0
`I
`0
`
`3
`
`0
`|
`0
`0
`0
`O
`0
`
`4
`
`I
`I
`O
`O
`0
`0
`0
`
`2
`
`3
`3
`3
`
`0
`2
`0
`
`3
`
`I
`0
`0
`0
`0
`2
`0
`
`4
`
`0
`0
`0
`0
`0
`0
`0
`
`2
`
`4
`0
`|
`0
`l
`2
`I
`
`3
`
`I
`0
`0
`0
`0
`I
`0
`
`4
`
`0
`0
`0
`0
`0
`0
`0
`
`2
`
`2
`2
`0
`0
`0
`I
`0
`
`3
`
`0
`0
`0
`0
`I
`0
`0
`
`4
`
`0
`0
`0
`0
`0
`0
`0
`
`2
`
`4
`2
`0
`0
`I
`3
`0
`
`3
`
`I
`I
`I
`0
`r
`0
`0
`
`4
`
`0
`0
`0
`0
`0
`0
`0
`
`2
`
`4
`3
`6
`0
`!
`I
`0
`
`3
`
`I
`I
`I
`0
`0
`3
`!
`
`4
`
`0
`0
`0
`0
`0
`0
`0
`
`* Both agents were administered on day I of each course~
`
`Sandoz Inc.
`Exhibit 1017-0003
`
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`

`
`92
`
`TH<~DTMANN ET AL
`
`schedule. When both agents are administered on
`day 1, the acute DLTs consist of leukopenia and
`neutropenia, in addition, delayed fatigue may be
`observed at high doses of MTA. No other phase 1
`combination studies with MTA have yet been
`reported, but our results concerning toxicity are in
`agreement with observations reported from single-
`agent phase 1 studies using this compound.6s
`Rinaldi et al,s using the same administration
`schedule of MTA, reported neutropenia, thrombo-
`cytopenia, and fatigue as being the DLTs, In
`contrast, we have not observed a significant
`proportion of patients with significant thrombocy-
`topenia, This difference might be due to the fact
`that Rinaldi et als escalated the dose of MTA to
`700 mg/mz while in the present study the highest
`MTA dose was 600 mg/mz.
`Of interest is that, in contrast to other single-agent
`clinical phase I and phase I| studies, we have not
`observed serious skin toxicity in patient cohort I.
`We hypothesize that the use of corticosteroids as part
`of the antiemetic prophylaxis regimen for cisplatin
`may have prevented the high incidence of severe
`skin toxicities as described by others. This conclusion
`is supported by the observation that administration
`ofcorticosteroids 24.hours after the administration of
`MTA in patient cohort 2 was accompanied by the
`occurrence of grade 3 skin reactions. After the din-
`ical manifestation of skin toxicity, however, cortico-
`steroids are used effectively for treatment,tt
`The combination of MTA and cisplatin has
`shown antitumor activity at various dose levels
`and in different tumor types. Of particular interest
`is the observation that four of seven patients with
`mesothelioma treated with this combination had
`confirmed partial responses. Reported single-agent
`response rates for cisplatin in this notoriously re-
`fractory malignancy are roughly 14%,t~ indicating
`that mesothelioma is a tumor type worthy of fur-
`ther investigation with this combination. How.
`ever, this conclusion is based on anecdotal obser-
`vations and the design of our phase I study does
`not allow for the estimation of response rotes.
`Further clinical studies of MTA/cisplatin in pa-
`tients with mesothelioma appear promising.
`We conclude from our study that MTA may be
`safely combined with cisp[atin. The day l/day 2
`split.dose schedule is inferior to the administration of
`both agents on day 1 with regard to toxicity and,
`possibly, activity. Prehydmtion regimens as used for
`cisp[atin do not appear to affect pharmacokinetic
`
`Abbr~vL~fion: PP~ parthl response,
`* Both agents were administered on ~ay I of each treatment
`
`tumor activity. To gather data regarding tlxis hy-
`pothesis, a second cohort of patients received
`MTA on day I without prehydration or antiemetic
`medication followed by cisplatin on day 2 after
`antiemetic premedication and hydration. Six pa-
`tients were treated on this schedule with 500
`mg]m2 MTA/75 mg/m2 cisplatin and four patients
`received 600 mg/mz MTA/100 mg!mz cispiatin.
`At the lower of the two dose levels, two patients
`developed grade 3 and one patient grade 4 leuko-
`penia, One patier~t experienced grade 3 and two
`patients grade 4 neutropenia. While no severe
`anemia or thrombocytopcnia was observed, one
`patient each developed grade 2 and 3 skin toxicity.
`Another patient developed grade 4 diarrhea fol-
`lowed by severe dehydration and sepsis during the
`second cycle and died due to these treatment-
`related complications, At the higher dose level,
`two patients experienced grade 3 leukopenia. An-
`other patient with recurrent head and neck cancer
`had a grade 4 mucositis requiring parentetat nutri-
`tion. This patient died while on study, most likely
`due to a catheter-related bacterial sepsis after re-
`covery from a short-lasting grade 4 neutropenia.
`
`COMMENTS
`
`The results of our present study indicate that it
`is clinically feasible and safe to combine MTA
`with cisplatin using a 3-week administration
`
`Sandoz Inc.
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`
`I~ASE | STUDY WITH FYI’A AND CISPLATIN
`
`93
`
`variables of MTA, although more mature data wilt
`be needed to support this hypothesis. Premed|cation
`with a single dose of steroids appears to prevent or
`ameliorate the occurrence of MTA-mediated skin
`toxicity. Additional clinical studies are planned to
`further define the activity of this combination in
`patients with malignant mesothelioma~, non-small
`cell lung cancer, and head and neck cancer.
`
`ACKNOWLEDGMENT
`
`The authors thank Dr U. Ohnmacht, M. Kemrnerich, and
`Mleke Akker for their expert help during this phase I study and
`the preparation of the manusctipt,
`
`REFERENCES
`
`1. Baldwin SW, Tse A, Taylor EC, et al: Structural features
`of 5,10-dideaza-5,6,7,8-tetmhydrofolate that determine inhibi-
`tion of mammalian glycinamide ribonucleotide formyltrans.
`fet’ose. Biocheraistr~ 30:1997.2006, t991
`2. Taylor EC, Kuhnt D, Shih C, et ah A dideazetetrah’idr~
`rotate analogue lacking a chiral center at C-6; No{4-[2-aminn-
`1,7.dihydro.4.oxopyrrolo[2,3.d]pyrlmidine.6.?l)ethyllbenzoyl}
`glutamlc acid, a new and potent inhibitor of thymidilate
`thane, J Med Chem 35;4450-4454, 1992
`3. Shih C, Chen V.1, Gos.sett LS, et al: LY 231514. A
`pyrrolo[2,3.dlpyrim|dine based antifolate that inhibits multiple
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`4. Tonklnson JL, Murder P, Andls SL, et ah Cell cycle
`effects of antifolate antimetabolites: Implication for cytotoxo
`
`ici~ and cytostasLs. Cancer Chemother Pharmaco139:521.540,
`1997
`5. Wormlla JF, Sell" TD, Theobald KS, et ah Effects of fot ic
`acid on toxtcl~ and antltumor activity of LY231514 multi-
`targeted antifolate (MTA), Proc Am Assoc Cancer Res 38:478,
`1997 (abstr)
`6. Rina|di DA, Burrts HA, Dorr FA, et ah Initial phase l
`evaluaticm of the novel thymidylate syuth~e inhibitor, LY
`231514, using the modified continual reassessment method for
`dose escalation, J Clin Oncol 13:284~-2850, 1995
`7. McDonald AC, Vasey PA, Walling J, et al: Phase I and
`pharmacokinetic study of LY 231514, the mutt|targeted anti-
`folate, administered by dally x 5, q 21 ~chedule. Ann Oncof
`7:20, 1996 (suppl 5) (abstr)
`8. Rlnaldi DA, Burrts HA, Dotr FA, et ah A phase i eval.
`uation of LY 231514, a novel multitargctcd antifolate, admin-
`istered cve~ 21 days. Proc Am ~ Clin Chtcol 16:A489, 1997
`
`9. Investigators Handbook. A Manual for Particip.anrs in
`Clinical Trials of lnvestigatlonal Agents Sponsored b? the
`Division of Cancer Treatment. Bcthesda, MD, Natiot~al Can-
`cer Institute. 1996
`10. The WHO Handbook for Reporting Results of Cartcer
`Treatment. Geneva, Switzerland, World Heahh Organization,
`1979
`I 1. Smith |E, Miles DW, Coleman RE, et ah Phase |I study
`of LY?.31514 (MTA) in patients (pts) with locally recurrent or
`metastatic breast cancer (LR/MBC)~n interim report. Proc
`Am Soc Clin Oncol 16:19lA, 1997 (abstr A67t)
`12. Antman KH~ Pass HI, Schtff PB: Benign and malignant
`me~othelioma, in DeVita VT, Hellman S, Rosenberg SA (eds):
`Cancer: Principles and Practice of Oncolog3, (ed 5). Phlhdcl.
`phla, PA, Lipplncott-Raven, 1997, pp t853-1878
`
`Sandoz Inc.
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