Combination therapy with gefitinib, an epidermal growth factor receptor tyrosine kinase inhibitor, gemcitabine and cisplatin in patients with advanced solid tumors.

BACKGROUND: The aim of this study was to investigate the tolerability, pharmacokinetic interaction and antitumor activity of gefitinib ("Iressa", ZD1839), an orally active, selective epidermal growth factor receptor tyrosine kinase inhibitor, combined with gemcitabine and cisplatin in chemotherapy-naïve patients with advanced solid tumors. PATIENTS AND METHODS: This was an open-label feasibility trial evaluating two doses of gefitinib (250 and 500 mg/day) in combination with gemcitabine and cisplatin. Gefitinib was administered daily from day 2 onwards. Gemcitabine 1250 mg/m(2) was given on days 1 and 8 and cisplatin 80 mg/m(2) on day 1 for up to six 3-week cycles. Patients could then continue to receive gefitinib monotherapy. RESULTS: Eighteen patients were entered, nine at each gefitinib dose level. Two patients developed dose-limiting toxicity: one grade 3 convulsion (250 mg/day dose group) and one grade 3 rash (500 mg/day dose group). The most frequently occurring adverse events in the combination phase were vomiting (17 patients), asthenia (16), nausea (14), diarrhea (14) and skin rash (13). The most common grade 3/4 adverse events were vomiting (seven patients), asthenia (six), thrombocytopenia (six), diarrhea (five) and anorexia (five). Pharmacokinetic analyses showed no apparent pharmacokinetic interaction between gefitinib and cisplatin or gemcitabine, with the exception of a possible small increase in the geometric mean exposure to gemcitabine seen on day 8 of therapy when given alone with the higher dose of gefitinib. Of 17 evaluable patients, nine had confirmed partial responses, seven had stable disease and one had progressive disease. CONCLUSIONS: Combination therapy of gefitinib with cisplatin and gemcitabine had a manageable and predictable safety profile, no major effect on exposure to any of the three drugs and antitumor activity.

Gefitinib ('Iressa', ZD1839) and new epidermal growth factor receptor inhibitors.

The epidermal growth factor receptor (EGFR) is a promising target for cancer therapy and a number of EGFR-targeted agents have been developed. Those most advanced in development are the EGFR tyrosine kinase inhibitors gefitinib ('Iressa', ZD1839) and erlotinib ('Tarceva', OSI-774), and the monoclonal antibody cetuximab ('Erbitux', IMC-C225). This review provides a clinical overview of these agents, highlighting their antitumour activities in different tumour types. Epidermal growth factor receptor-targeted agents are generally well tolerated and are not typically associated with the severe adverse events often seen with cytotoxic chemotherapy. Gefitinib is the agent with the most extensive clinical experience, particularly in non-small-cell lung cancer (NSCLC). Recently, gefitinib became the first-approved EGFR-targeted agent, for use in patients with previously treated advanced NSCLC in Japan, the USA and other countries. Further studies are required to explore the full potential of these novel agents either as monotherapy or combination therapy.

Phase I safety, pharmacokinetic, and pharmacodynamic trial of ZD1839, a selective oral epidermal growth factor receptor tyrosine kinase inhibitor, in patients with five selected solid tumor types.

PURPOSE: To establish the safety and tolerability of ZD1839 (Iressa), a selective epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, and to explore its pharmacokinetic and pharmacodynamic effects in patients with selected solid tumor types. PATIENTS AND METHODS: This was a phase I dose-escalating trial of oral ZD1839 150 mg/d to a maximum of 1,000 mg/d given once daily for at least 28 days. Patients with either advanced non-small-cell lung, ovarian, head and neck, prostate, or colorectal cancer were recruited. RESULTS: Eighty-eight patients received ZD1839 (150 to 1,000 mg/d). At 1,000 mg/d, five of 12 patients experienced dose-limiting toxicity (grade 3 diarrhea [four patients] and grade 3 somnolence [one patient]). The most frequent drug-related adverse events (AEs) were acne-like rash (64%) and diarrhea (47%), which were generally mild (grade 1/2) and reversible on cessation of treatment. No change in ZD1839 safety profile was observed with prolonged administration. Pharmacokinetic analysis showed steady-state exposure to ZD1839 in 98% of patients by day 7. Nineteen patients had stable disease and received ZD1839 for >or= 3 months; seven of these patients remained on study drug for >or= 6 months. Serial skin biopsies taken before treatment and at approximately day 28 revealed changes indicative of inhibition of the EGFR signaling pathway. CONCLUSION: ZD1839 was generally well tolerated, with manageable and reversible AEs at doses up to 600 mg/d and dose-limiting toxicity observed at 1,000 mg/d. ZD1839 treatment resulted in clinically meaningful disease stabilization across a range of tumor types and doses. Pharmacodynamic changes in skin confirmed inhibition of EGFR signaling, which was predicted from the mode of action of ZD1839.

The tyrosine kinase inhibitor ZD1839 ("Iressa") inhibits HER2-driven signaling and suppresses the growth of HER2-overexpressing tumor cells.

The epidermal growth factor receptor (EGFR) is commonly overexpressed in many human tumors and provides a new target for anticancer drug development. ZD1839 ("Iressa"), a quinazoline tyrosine kinase inhibitor selective for the EGFR, has shown good activity in preclinical studies and in the early phase of clinical trials. However, because it remains unclear which tumor types are the best targets for treatment with this agent, the molecular characteristics that correlate with tumor sensitivity to ZD1839 have been studied. In a panel of human breast cancer and other epithelial tumor cell lines, HER2-overexpressing tumors were particularly sensitive to ZD1839. Growth inhibition of these tumor cell lines was associated with the dephosphorylation of EGFR, HER2, and HER3, accompanied by the loss of association of HER3 with phosphatidylinositol 3-kinase, and down-regulation of Akt activity. These studies suggest that HER2-overexpressing tumors are particularly susceptible to the inhibition of HER family tyrosine kinase signaling and suggest novel strategies to treat these particularly aggressive tumors.

Phase I study of ZD9331 on short daily intravenous bolus infusion for 5 days every 3 weeks with fixed dosing recommendations.

PURPOSE: To conduct a phase I study of ZD9331, a potent, nonpolyglutamatable thymidylate synthase inhibitor using a short daily infusion for 5 consecutive days every 21 days. PATIENTS AND METHODS: Patients with refractory cancer or cancer for which no standard therapy was available were treated in escalating doses using an accelerated titration design. Plasma and urine samples were collected at timed intervals in the first cycle for pharmacokinetic analysis. RESULTS: Seventy-four patients were enrolled at 12 dose levels from a starting dose of 0.4 mg/m(2)/d to 16 mg/m(2)/d and 25 mg/d fixed dosing, of which 67 were assessable for toxicity. Maximum-tolerated dose was reached at 16 mg/m(2)/d. Myelosuppression was dose-limiting, consisting of thrombocytopenia associated with neutropenic fever. Body-surface area did not correlate with drug clearance; therefore, fixed daily dosing of 25 mg/d was studied and found to be tolerable, with two of 12 dose-limiting events. Dose-limiting nonhematologic toxicity consisted of grade 3 erythematous maculopapular rash observed in one patient at 12 mg/m(2)/d and one patient at 25 mg/d. Pharmacokinetic analysis showed nonlinearity, with clearance increasing with dose. The mean clearance and terminal half-life of the drug were 6.6 +/- 2.0 mL/min and 71.3 +/- 27.0 hours, respectively. Area-under-the concentration-time curve was a better predictor of toxicity than dose, using multiple linear regression analyses. Minor response (40% shrinkage of tumor) was observed in one patient with colorectal cancer treated at 12 mg/m(2)/d. CONCLUSION: The recommended dose for ZD9331 on this schedule is 25 mg/d. Neutropenia, thrombocytopenia, and rash were dose-limiting, and efficacy studies in colorectal cancer are indicated.

ZD1839 ('Iressa') as an anticancer agent.

ZD1839 ('Iressa') is an orally active, selective epidermal growth factor receptor-tyrosine kinase inhibitor which blocks signal transduction pathways implicated in the proliferation and survival of cancer cells and other host-dependent processes promoting cancer growth. In preclinical studies, ZD1839 produced reversible growth inhibition and growth delay in a wide range of tumour cell lines and human tumour xenografts. Moreover, this activity was enhanced when ZD1839 was coadministered with cytotoxic agents. Preliminary results from phase I trials in patients with advanced disease and a wide variety of tumour types suggest that ZD1839 has an acceptable tolerability profile and promising clinical efficacy, particularly in non-small cell lung cancer (NSCLC). ZD1839 is currently in phase III clinical development for the treatment of advanced NSCLC. In addition, further trials are ongoing or planned in a number of other tumour types.

Anti-EGF receptor therapy.

The epidermal growth factor receptor (EGFR) signalling pathway contributes to a number of processes important to tumour progression, including cell proliferation, apoptosis, angiogenesis and metastatic spread. EGFR signalling is thought to be an important cell survival mechanism in hormone-resistant prostate cancer. ZD1839 ('Iressa') is an orally active, selective EGFR-tyrosine kinase inhibitor (EGFR-TKI) which blocks signal transduction pathways implicated in promoting cancer growth. In preclinical studies, ZD1839 alone, and in combination with cytotoxic agents, produced reversible growth inhibition and growth delay in a wide range of tumour cell lines and human tumour xenografts. Preliminary results from phase I trials in patients with advanced disease suggest that ZD1839 has an acceptable tolerability profile and promising clinical efficacy in patients with a variety of tumour types, including hormone-resistant prostate cancer, where new treatment strategies are needed. Prostate Cancer and Prostatic Diseases (2000) 3, 296-302

Hypertensive crises induced by treatment of malignant pheochromocytoma with a combination of cyclophosphamide, vincristine, and dacarbazine.

Combination chemotherapy with cyclophosphamide, vincristine, and dacarbazine (CVD) is an effective treatment regimen for malignant pheochromocytoma. There have not been any significant acute cardiovascular effects reported following CVD treatment. Among seven patients with malignant pheochromocytoma treated with CVD at our institution, two patients with labile hypertension developed hypertensive crisis following CVD treatment. The marked increase in blood pressure correlated with an increase in urinary excretion of catecholamine metabolites in one patient. Further hypertensive crises following subsequent CVD treatments were avoided by optimizing each patient's antiadrenergic therapy. Similar to the approach used preoperatively for patients with resectable pheochromocytoma, maximal antiadrenergic therapy is essential in preventing hypertensive crises in patients with malignant pheochromocytoma undergoing CVD treatment.

Treatment of advanced medullary thyroid carcinoma with a combination of cyclophosphamide, vincristine, and dacarbazine.

BACKGROUND: Medullary thyroid carcinoma (MTC) is a neoplasm of the parafollicular C cells of the thyroid gland, which belongs to the diffuse neuroendocrine system. This cancer usually behaves in a relatively indolent manner for most patients. However, approximately 20% of patients have a more aggressive course that requires effective management. There are few reported clinical trials of chemotherapy for MTC. From the literature, the most active agent appears to be doxorubicin, with response rates of 30% reported. On the basis of the activity of cyclophosphamide, vincristine, and dacarbazine (CVD) in other advanced neuroendocrine neoplasms, the authors tested the combination in patients with advanced MTC. METHODS: Seven patients with advanced MTC were treated with cyclophosphamide (750 mg/m2), vincristine (1.4 mg/m2), and dacarbazine (600 mg/m2 daily for 2 days in each cycle) every 3 weeks. Assessments of measurable tumor and serum calcitonin and carcinoembryonic antigen were made before treatment and followed up until progressive disease was documented. RESULTS: Two patients had partial tumor and biochemical responses for a duration of 14 and 29 months, respectively. One patient had a partial biochemical response and stable tumor measurements for 9 months, and another patient had stable tumor size and markers for 14 months. Three patients had progressive disease. Diarrhea and flushing improved in two patients who had partial biochemical responses. CONCLUSION: Our experience suggests that CVD chemotherapy has moderate activity and is well tolerated in patients with advanced MTC. Additional prospective studies of this regimen for MTC are required.

New bisphosphonates in the treatment of bone metastases.

Normal skeletal integrity is maintained by physiological bone turnover through a coupled process of bone resorption, mediated by osteoclasts, followed by new bone formation, mediated by osteoblasts. Major features of the pathogenesis of cancer-associated skeletal destruction are enhanced osteoclast-mediated bone resorption and disruption of normal bone formation. In this article, the literature on the pathogenesis and clinical manifestations of metastatic bone disease is discussed. Animal and clinical trials investigating novel bone targeted agents, emphasizing the bisphosphonates, are critically assessed. The most frequent clinical manifestations of bone metastases are pain, fracture, immobility, spinal cord compression, and hypercalcemia. New treatments under study for patients with bone metastases include agents specifically targeted to the skeleton such as bone-seeking radioisotopes and bisphosphonates. Studies in animal models of metastatic bone disease show that these bisphosphonates are able to inhibit tumor-induced osteolysis and are potentially useful in this condition. Bisphosphonates have been investigated in several clinical trials of patients with skeletal metastases from breast cancer, prostate cancer, and multiple myeloma. Overall, the studies investigating bone targeted radioisotopes or bisphosphonates for the treatment of morbidity due to skeletal metastases have been inconclusive. An improved understanding of the pathogenesis of metastatic bone disease and preclinical studies with bisphosphonates suggest that these agents may have a role in the treatment of this disorder. Additional trials of new generation bisphosphonates, employing a rigorously controlled, randomized study design with adequate numbers of subjects, are needed to demonstrate the safety and efficacy of this class of agents in this setting.

Dose-response study of alendronate sodium for the treatment of cancer-associated hypercalcemia.

PURPOSE: A randomized, double-blind, dose-ranging study of single-dose intravenous (IV) therapy with alendronate sodium (aminohydroxybutylidene bisphosphonate) was performed in patients with cancer-associated hypercalcemia. PATIENTS AND METHODS: Patients with hypercalcemia who had not received antitumor therapy in the preceding 7 days were treated with 48 hours of IV hydration. Patients with persistent hypercalcemia (albumin-corrected serum calcium concentration [CSCC] > or = 11.5 mg/dL) were randomly assigned to receive 2.5, 5, 10, or 15 mg of alendronate infused over 2 hours, or 10 mg of alendronate infused over 24 hours. Fifty-nine patients were treated and 50 patients were assessable for the dose-response relationship. RESULTS: Normalization of CSCC (< or = 10.5 mg/dL) was achieved in 22%, 82%, 75%, and 90% of assessable patients in the 2.5-, 5-, 10- (2- and 24-hour groups pooled), and 15-mg dose groups, respectively, within 8 days of therapy. Doses > or = 5 mg were significantly superior to the 2.5-mg dose level (P < .05). There was no significant difference in the minimum CSCC achieved between the 2- and 24-hour infusions of the 10-mg dose. Based on an intent-to-treat analysis of all randomized patients, the overall complete response rate was 74% for dose levels greater than 2.5 mg. For assessable patients who responded to > or = 5 mg of alendronate, the estimated median duration of normocalcemia was 10 days (range, 1 to 25). The estimated median time to relapse (CSCC > 11.5 mg/dL) was 15 days from initial treatment and 12 days from initial response, respectively. Adverse events included a transient febrile response in 34% of patients and eight episodes of reversible elevations in serum transaminase levels among treated patients. CONCLUSION: While a statistically significant dose-response relationship was not clearly evident at doses greater than 5 mg, single doses of > or = 5 mg alendronate sodium effectively lowered serum calcium concentrations and were well tolerated in the treatment of cancer-associated hypercalcemia.

Pheochromocytoma presenting as a skull metastasis with massive extracranial and intracranial extension.

A case of metastatic pheochromocytoma is reported in which the diagnosis was determined on the basis of a painless scalp mass. Subsequent to biopsy and histological diagnosis, further investigations revealed a large skull lesion with intracranial extension, an adrenal mass, and various catecholamine abnormalities. The radiological characteristics and operative findings of this case are described, and the literature regarding pheochromocytoma with intracranial metastatic extension is reviewed.

Neuropeptide Y expression distinguishes malignant from benign pheochromocytoma.

No reliable gross or microscopic features distinguish benign from malignant pheochromocytomas. The diagnosis of malignant pheochromocytoma is based solely on the presence of regional or distant metastases. This study evaluated the expression of neuropeptide Y messenger RNA (mRNA) in nine benign and 11 malignant pheochromocytomas and has found that neuropeptide Y mRNA was expressed in all nine benign tumors but in only four of 11 malignant tumors (P = .0084). These data suggest that the determination of neuropeptide Y expression in the evaluation of patients with pheochromocytoma may have prognostic significance.

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery for brain-injured patients: reliability and validity.

The purpose of this study was to determine the reliability and validity of the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery. The battery provides an initial profile of the cognitive abilities of the brain-injured patient that can be used as a starting point for occupational therapy intervention and as a screening test for further assessment. The LOTCA consists of 20 subtests and is divided into four areas: orientation, visual and spatial perception, visuomotor organization, and thinking operations. The battery takes 30 to 45 minutes to administer. Subjects in the study consisted of two patient groups (20 traumatic head injury patients and 28 cerebrovascular accident patients) and one control group (55 non-brain-injured adults). Results showed interrater reliability coefficients of .82 to .97 for the various subtests and an alpha coefficient of .85 and above for the internal consistency of the areas of perception, visuomotor organization, and thinking operations. The Wilcoxon two-sample test showed that all subtests differentiated at the .0001 level of significance between the patient groups and the control group. This supported the LOTCA's validity. Furthermore, factor analysis provided initial construct validation for three areas of the battery: perception, visuomotor organization, and thinking operations.

Altered regulation of P-450IA1 expression in a multidrug-resistant MCF-7 human breast cancer cell line.

MCF-7 human breast cancer cells, selected for resistance to adriamycin (AdrR), exhibit the phenotype of multidrug resistance (MDR). Previous studies have shown that resistance in AdrR MCF-7 cells is associated with several biochemical changes that are similar to those induced in rat hyperplastic nodules, preneoplastic liver lesions which display broad spectrum resistance to carcinogens and hepatotoxins. In this report, we show that these changes in the AdrR MCF-7 cells are also associated with the development of cross-resistance to the procarcinogen benzo(a)pyrene (BP) and are associated with a marked defect in the conversion of BP to its cytotoxic, carcinogenic metabolites by AdrR cells. Since aryl hydrocarbon hydroxylase is the principle enzyme activity which converts benzo(a)pyrene to toxic hydroxylated forms, the regulation of cytochrome P-450IA1 expression, the gene encoding this enzyme activity in MCF-7 cells, was examined. Incubation with 100 nM 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) for 24 h results in a marked increase in aryl hydrocarbon hydroxylase activity in wild type (WT) but not AdrR MCF-7 cells. The alteration in aryl hydrocarbon hydroxylase expression in the AdrR cells is not overcome by incubation either with higher concentrations of TCDD (1 microM) or for longer periods of time (4 days). Northern blot analysis indicates that this defect in AdrR MCF-7 cells involves a regulatory defect at the level of P-450IA1 RNA. Following transfection of a construct containing the normal mouse P-450IA1 promoter fused to a reporter gene (bacterial chloramphenicol acetyltransferase) into WT and AdrR MCF-7 cells, TCDD induced chloramphenicol acetyltransferase activity in WT MCF-7 cells only. Furthermore, TCDD also induces both DT-diaphorase and UDP-glucuronyltransferase activities in WT, but not AdrR cells. These data suggest that the defect in the AdrR MCF-7 cells is not due to a structural P-450IA1 gene mutation, but rather involves a product regulating the polycyclic hydrocarbon-inducible expression of several drug-metabolizing enzyme activities. This defect in the AdrR MCF-7 cells is also associated with the development of resistance to ellipticine, an anticancer agent which is converted to more toxic hydroxylated species by aryl hydrocarbon hydroxylase or a similar mixed function oxidase. The WT and AdrR MCF-7 cells represent a useful model to study the regulation of the P-450IA1 gene in human cells.

Malignant pheochromocytoma: effective treatment with a combination of cyclophosphamide, vincristine, and dacarbazine.

STUDY OBJECTIVE: To determine the efficacy and toxicity of combination chemotherapy in patients with advanced, malignant pheochromocytoma. DESIGN: Nonrandomized, single-arm trial. SETTING: Governmental medical referral center. PATIENTS: Fourteen patients with malignant pheochromocytoma confirmed by histologic tests. All patients had metastatic disease and elevated urinary catecholamine secretion. INTERVENTIONS: After optimization of antihypertensive therapy, patients received cyclophosphamide, 750 mg/m2 body surface area on day 1; vincristine, 1.4 mg/m2 on day 1, and dacarbazine, 600 mg/m2 on days 1 and 2, every 21 days. MEASUREMENTS AND MAIN RESULTS: Combination chemotherapy with cyclophosphamide, vincristine, and dacarbazine produced a complete and partial response rate of 57% (median duration, 21 months; range, 7 to more than 34). Complete and partial biochemical responses were seen in 79% of patients (median duration, more than 22 months; range, 6 to more than 35). All responding patients had objective improvement in performance status and blood pressure. Toxicity included expected hematologic, neurologic, and gastrointestinal effects of chemotherapy without serious sequelae. There were four minor hypotensive episodes and one minor hypertensive episode. CONCLUSIONS: Combination chemotherapy with cyclophosphamide, vincristine, and dacarbazine is effective for advanced malignant pheochromocytoma. Urinary catecholamines are useful to ascertain biochemical response to therapy.