A Phase I and Pharmacokinetic Study of Melphalan Using a 24-Hour Continuous Infusion in Patients with Advanced Malignancies

Vol. 6, 57–63, January 2000 Clinical Cancer Research 57

A Phase I and Pharmacokinetic Study of Melphalan Using a 24-hour Continuous Infusion in Patients with Advanced Malignancies

Fre´de´ric Pinguet,1 Ste´phane Culine, ble with a one-compartment model. Relationships have been Françoise Bressolle, Cećile Astre, found between the area under the plasma concentration- time curve and doses and between C and doses. Moreover, Marie-Pierre Serre, Claude Chevillard, and ss clearance, t1/2 elimination, and volume of distribution did Michel Fabbro not change statistically with dose, which suggests linear Oncopharmacology Department, Pharmacy Service [F. P., F. B., kinetics. Two partial responses were observed in patients C. A., M-P. S.] and Department of Medicine [S. C., M. F.], with ovarian carcinoma or adenocarcinoma of unknown Anticancer Center, Centre Re´gional de Lutte contre le Cancer, 34298 Montpellier Cedex 5; Clinical Pharmacokinetic Laboratory, Faculty of primary origin, and another patient had stabilization dis- Pharmacy, University Montpellier I, Montpellier 34060 Cedex 2 ease. In conclusion, melphalan MTD was determined to be [F. B.]; and Institut National de la Santeét de la Recherche Me´dicale 30 mg/m2 when administered as a 24-h infusion. Hemato- (INSERM) U469, Centre National de la Recherche Scientifique- logical toxicity was the dose-limiting toxicity. The most im- INSERM Pharmacology Endocrinology, Montpellier 34298 Cedex 5 [C. C.], France portant nonhematological toxicity encountered was nausea and vomiting. The recommended dose for Phase II studies was 30 mg/m2. ABSTRACT The objectives of the present study were to determine INTRODUCTION the following: (a) the maximum tolerated dose (MTD) of Melphalan was introduced into clinical use in the late melphalan using a 24-h continuous infusion; (b) the clinical 1950s and has since been established as an agent with a wide toxicity; and (c) the pharmacokinetic characteristics of mel- spectrum of antitumor activity (1, 2). It is extensively used in the phalan at each dose level. Twenty-one patients with refrac- treatment of multiple myeloma, ovarian cancer, breast cancer, tory solid tumors were enrolled in the study. Melphalan, and neuroblastoma (3–5). Melphalan is an alkylating agent of packaged in 3% sodium chloride, was administered i.v. over the bischloroethylamine type that exerts a cytotoxic effect a 24-h period. Patients were assigned to one of three esca- through the formation of interstrand or intrastrand DNA cross- b)30 links or DNA-protein cross-links via its two chloroethyl groups) ;(5 ؍ lating dose levels of melphalan: (a) 20 mg/m2 (n .(Each patient (1 .(6 ؍ and (c) 40 mg/m2 (n ;(7 ؍ mg/m2 (n underwent pharmacokinetic evaluation during the first cy- Founded on the pharmacokinetic principles of phase-spe- cle of treatment. Melphalan concentrations in plasma were cific, plasma half-life, and stability in solution, infusional sched- determined by high-performance liquid chromatography. ules for chemotherapy administration represent a rational Toxicity was evaluated after each course of chemotherapy. method for the delivery of many antineoplastic agents. For All of the patients were assessable for toxicity and pharma- several antimitotic drugs, long-term continuous infusion in- cokinetics, and 20 patients were assessable for response creased therapeutic activity or improved the therapeutic index analysis. A total of 50 courses of melphalan was studied. The by decreasing toxicity (6). MTD was 30 mg/m2. The dose-limiting toxicity was neutro- Bosanquet and Bird (7) studying in vitro degradation of penia and thrombocytopenia. Hematotoxicity was reversible melphalan reported that continuous exposure of melphalan in (nadir, 14–15 days; recovery, 3.5 and 12.5 days for 30 and 40 chemosensitivity assays is probably preferable to the arbitrary mg/m2, respectively), cumulative, and related to the admin- 1-h exposure commonly used. Moreover, Teicher et al. (8) istered dose and to the history of previous therapy. There indicated that in vitro continuous administration of melphalan were six episodes of neutropenic sepsis. Individual pharma- could be at least as cytotoxic as bolus administration of the same cokinetic parameters were estimated using a Bayesian ap- dose on MCF7 breast cancer cells. In a recent in vitro study, we proach and linear elimination kinetics. Data were compati- have shown that protracted infusion of melphalan had a higher cytotoxic effect than bolus administration on 8226 (myeloma) and A2780 (ovarian) cancer cell lines (9). On the basis of in vitro study and pharmacokinetic (2) 2 Received 6/4/99; revised 9/30/99; accepted 10/4/99. considerations (short half-life, small Vd, and low protein- The costs of publication of this article were defrayed in part by the binding capacity), melphalan is a good candidate for continuous payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. 1 To whom requests for reprints should be addressed, at Laboratoire d’Onco-Pharmacologie, Service pharmacie, Centre Re´gional de Lutte 2 The abbreviations used are: Vd, volume of distribution; MTD, maximum contre le Cancer, 34298 Montpellier Cedex 5, France. Phone: 33-4-67- tolerated dose; ECOG, Eastern Cooperative Oncology Group; Cl, clear-

61-31-95; Fax: 33-4-67-61-30-96. ance; t1/2 elim, elimination half-life; AUC, area under the plasma concen-

infusion. Significant intra- and interpatient variabilities in phar- were excluded from the study. A total of six cycles per patient macokinetic parameters have been shown. After short i.v. infu- was planned. sion, the distribution half-life ranged from 5 to 15 min, and the The study protocol was reviewed and approved by the

t1/2 elim from 17 to 75 min (10–12) or from 2 to 4 h (13) Total institutional review board. It was performed in accordance with plasma Cl ranged from 92 to 961 ml/min/m2. The Vd was found the Declaration of Helsinki, and with current European Com- to be greater than the total-body water (35.5–185.7 liters/m2), munity and United States Food and Drug Administration guide- although lower values have been reported (8 and 50 liters/m2;1, lines for good clinical practice. The patients were fully informed 10–16). about the procedure and the purpose of the experiment and gave However, in clinical practice, melphalan must be prepared written consent. extemporaneously before administration because its rapid deg- Treatment Regimen. Melphalan was administered over radation in conventional 0.9% sodium chloride at ambient tem- a 24-h period. The drug was dissolved in four syringes of 60 ml perature prohibits its use in continuous infusion (17). Thus, the of 3% sodium chloride; each syringe was administered i.v. over manufacturer recommends use of this drug within 1.5 h after 6 h through a central venous catheter using a two-way portable constitution. Degradation has been reported to be a function of infusion pump. Before administration, syringes were stored at sodium chloride concentration, temperature, and pH. In a pre- ϩ4°C (in these conditions melphalan was stable for 48 h). The viously published work (17), we have optimized the stability first dose-step of melphalan consisted of 20 mg/m2. Dose esca- conditions of melphalan. In 3% sodium chloride, the drug was lations were 10 mg/m2 and were to proceed after at least five stable for up to6hatroom temperature, which allowed a longer patients had successfully completed therapy at a given dose infusion time. level. Chemotherapy was repeated every 3 weeks. If WHO Here, we conducted a Phase I trial in adult patients who had grade 4 toxicity occurred in one patient at a given dose, at least various types of cancer that were refractory to conventional four additional patients were enrolled at that level before dose therapy and who received continuous constant infusion of mel- escalation. If grade 4 toxicity occurred in five patients at a given phalan for 24 h. The objectives of this study were to determine dose, escalation was stopped. the MTD of melphalan and to evaluate its toxicity and its Response Criteria. Tumor measurements were repeated antitumor activity as well as its pharmacokinetic characteristics once every two to three treatment cycles. Moreover, at the end at each dose. of treatment, patients were evaluated for response by physical examination, chest X-ray, and computerized axial tomography PATIENTS AND METHODS of the abdomen and/or chest when appropriate. Tumor response definition was based on WHO criteria. Patients designated com- Requirements for Patient Enrollment. Twenty-one pa- plete responders (CR) attained complete resolution of all disease tients, ages 18–74 years, with histologically documented ma- lasting for at least 4 weeks. A partial response (PR) was defined lignancies, admitted to the Medical Oncology Service of Anti- as a Ն50% reduction in the sum of products of bidirectionally cancer Center (Montpellier, France), were considered eligible measurable tumors without the appearance of new lesions. Pa- for this study. They had a performance status of 0–2 on the tients with stable disease had tumor measurements within 25% ECOG scale. Each patient underwent an initial evaluation, in- of on- study measurements lasting for at least 4 weeks without cluding (a) history and physical examination; (b) histopatholog- development of new lesions. Progressive disease (PD) was ical review; (c) chest X-ray; (d) pulmonary function test; (e) considered as the appearance of any new lesions or a more than computerized tomodensitometry of the brain, thorax and abdo- 25% increase in the sum of products. men; (f) and bone scan. Laboratory tests included: (a) complete Toxicity Evaluation. Patients were assessed after each hematology; (b) liver function (serum bilirubin, aminotrans- course of chemotherapy by clinical examination and by serum ferases, ␥-glutamyl-aminotransferase, alkaline phosphatase, and and urinary parameters studies to evaluate possible bone mar- serum proteins); (c) renal function (serum urea, serum creati- row, renal, or liver toxicity. Toxicity was defined according to nine, creatinine clearance calculated according to Cockcroft and the Cancer Therapy Evaluation Program’s common toxicity Gault; Ref. 18); and (d) serology (HIV, hepatitis B and C virus, criteria and graded 1 to 4. Dose-limiting toxicity was defined as and cytomegalovirus). All of the subjects were negative for HIV irreversible grade 2 nonhematological toxicity, reversible grade virus and hepatitis B and C. Patients with granulocytes Ͻ 3 nonhematological toxicity, or grade 4 hematological toxicity. 1500/mm3, platelets Ͻ 100,000/mm3, significant renal dysfunc- The recommended MTD dose was defined as the dose below tion (creatinine clearance Ͻ 50 ml/min), significant hepatic that causing dose-limiting toxicity. dysfunction (serum bilirubin Ͼ 2.5 times normal or alanine Pharmacokinetic Analysis. During the first cycle of aminotransferase, aspartate aminotransferase Ͼ four times nor- treatment each patient underwent pharmacokinetic evaluation. mal), significant pulmonary dysfunction (forced expiratory vol- Blood samples for determination of melphalan concentrations ume in 1 s, forced vital capacity, or transfer factor for carbon were obtained during the infusion at 2, 8, 23, 23.25, 23.5, 23.75, monoxide Ͻ 65% of the predicted values), or significant cardiac and 24 h and, after the end of the infusion, at 15, 30, 45, 60, and dysfunction (isotopic left ventricular ejection fraction Ͻ 50%) 75 min and 2 and 4 h. Blood was collected in heparinized tubes and immediately centrifuged. Plasma was removed and frozen at Ϫ20°C until assay. The plasma concentration versus time data for each patient were subjected to pharmacokinetic analysis using the P-PHARM software (19). Individual pharmacokinetic tration-time curve; Css , observed plasma concentration at steady-state; HPLC, high-performance liquid chromatography; NS, not significant. parameters were estimated using a Bayesian methodology that

combines the prior knowledge of the mean and dispersion of the Table 1 Patient characteristics pharmacokinetic parameters in the population to which the Characteristics No. of patients selected individual belongs and the individual samples. Such an Total patients 21 approach avoided a possible bias in the estimation of the elim- Female/Male 10/11 ination half-life. Indeed, at the low dose (20 mg/m2) for the last Age, years sampling times, melphalan concentrations were below the limit Median: 54 of quantitation of the analytical method. Preliminary analysis Range: 18–74 Performance status revealed that the data were best fitted by a one-compartment ECOG 1 10 model (on the basis of the examination of the Akaike criterion, ECOG 2 11 the objective function, and the residuals distribution) and that Previous treatment the residuals distribution showed that the error variance was Chemotherapy 21 Radiotherapy 11 better described by a heteroscedastic (proportional to the Primary tumors squared value of the predictions) model. The structural model Osteosarcoma 5 was parametrized in terms of Vd and Cl. From the resulting Unknown primary 3 individualized parameter values, the t elim and the AUC were Ovary 3 1/2 Non-small cell lung cancer 2 calculated as follows: Myeloma 2 Others 6 Vd ϫ 0.693 t elim ϭ 1/2 Cl

and RESULTS Patient Characteristics. The main clinical characteris- dose tics of the patients entering this study are listed in Table 1. All AUC ϭ Cl of the patients had advanced-stage disease at the time of the initiation of treatment. All of them had received conventional chemotherapy protocols previously, and most of them had re- respectively. C is the observed plasma concentration at steady- ss ceived prior radiotherapy. A total of 50 courses of melphalan state. C and AUC were normalized to a 20 mg/m2 administered ss were given, with a median of 2.4 courses per patient (range, one dose. to six). The starting dose level was 20 mg/m2 (five patients, 14 Determination of Melphalan Concentration in Plasma courses); the dose was escalated to 30 mg/m2 (nine patients, 23 Samples by HPLC. Melphalan concentrations in plasma were courses), 40 mg/m2 (seven patients, 13 courses) in cohorts of assayed by HPLC with UV detection (254 nm) using the method newly enrolled patients. described previously (20). The procedure involves the addition All of the patients were assessable for toxicity, and 20 of an internal standard (propylparaben) followed by treatment of patients were assessable for response. the samples with methanol. The HPLC column, Ultrasphere C18 ϫ ␮ (250 4.6 mm, 5 m), was equilibrated with an eluent mixture Toxicity consisting of methanol/water/acetic acid (49.5:49.5:1). Calibra- Hematological Toxicity. Prestudy neutrophil, platelet, ␮ tion standards were prepared in the range of 0.020 to 50 g/ml and hemoglobin levels were within the normal range. As ex- Ͻ Within- and between-day variabilities of the method were 8%. pected, neutropenia was the main hematological toxicity (Table The limit of quantitation was 10 ng/ml; at this level the analyt- 2). The median time to leukocyte and neutrophil nadirs occurred ical error averaged 20%. at 15 days (range, 13–18) and 14 days (range, 9–21 for the 30- Quality-control samples were included in each analytical and 40-mg/m2 dose level, respectively. The median time to sequence to verify the stability of samples during storage and recovery to pretreatment values was 3.5 days (range: 1–9) at 30 the accuracy and precision of analysis. Each determination was mg/m2 and 12.5 days (range: 1–23) at 40 mg/m2. Grade 4 performed in duplicate. neutropenia developed in 38% (19 courses) of the cycles, and The HPLC assay is specific for melphalan, and no inter- the median duration of neutropenia lower than 0.5 ϫ 103/␮l was action was detected with other drugs given to the patients. The 3 (range, 1–8) days and 11 (range, 1–20) days after adminis- mono- and dihydroxy-metabolites were not analyzed because tration of 30 and 40 mg/m2, respectively. Neutropenia showed a they have shown no evidence of cytotoxicity. high degree of interpatient variability. It seemed to be dose- Statistical Analysis. The results are expressed as related; grade 3–4 neutropenia was observed in 0, 55, and 71% mean Ϯ SD. of the cycles at 20, 30, and 40 mg/m2, respectively. Episodes of Plasma concentrations and AUC were plotted against dose. neutropenic fever were reported in six patients (2 at 30 mg/m2 Linear regression was performed using unweighted least- and 4 at 40 mg/m2). In five cases, fever episodes were bacteri- squares analysis of the data. The significance of the regression ologically documented: Escherichia coli in two cases, Entero- was confirmed using the F test. coccus faecalis in one case, Streptococcus D in one case, and A Kruskal-Wallis test was performed to compare normal- Proteus mirabilis in one case. 2 ized (to a 20 mg/m dose) AUC and Css, Cl, Vd, and the t1/2 elim Trombocytopenia was always associated with grade 3–4 across doses. neutropenia. Grade 4 thrombocytopenia was observed in four

Table 2 Hematological toxicity according to dose level of melphalan Anemia grade Neutropenia grade Thrombocytopenia grade Dose No. of (mg/m2) na patients 012340123401234 20145 221 4 1 311 30239 1332 2 23231 32 40137 2 1222 142 1 4 a n, number of courses.

Table 3 Nonhematological toxicity for all dose levels (N ϭ 50) During this study, mucositis was not observed. Grade Mild elevations of alkaline phosphatase (WHO grade 1, three patients) and ␥-glutamyl-aminotransferase (WHO grade 2, 1234 four patients) were observed. Alkaline phosphatase elevation of Nausea/Vomiting 1210 greater than 130 times normal (WHO grade 4) occurred in one Anorexia 0200 patient treated with 20 mg/m2 of melphalan; for this patient the Fatigue 0110 Diarrhea 1000 other liver tests were in the normal range. Prior chemotherapy Fever 2410 with high-dose methotrexate (about 2 years ago) might explain Pain 0100 such results. Alkaline phosphatase 3001 ␥-glutamyl-aminotransferase 0400 Confusion, hallucination 0300 MTD The MTD was 30 mg/m2 (Table 2). At this dose, at the first course, four patients (40%) of seven had grade 4 thrombocytopenia and neutropenia, and only 10% of patients showed anemia; these percentages did not increase over the successive patients and two patients treated at doses of 40 mg/m2 and 30 courses of chemotherapy. The 30 mg/m2 dose was tolerable for mg/m2, respectively. Grade 3 thrombocytopenia was observed two to six courses according to the patient. The study was closed in three patients treated at 30 mg/m2. At the dose level of 20 to enrollment after the development of significant toxicity at mg/m2, no grade Ͼ1 was observed. Twenty-six cycles (52%) highest dose (40 mg/m2), and no additional patients were en- were associated with thrombocytopenia of at least grade 3, and rolled. packed thrombocyte infusions were given on 2, 7, and 16 occasions after the administration of 20, 30, and 40 mg/m2, respectively. Recovery occurred at 5.5 (range, 4–7), 2.1 (range, Pharmacokinetic Characteristics of Melphalan 1–6), and 5.4 (range, 1–37) days at 20, 30, and 40 mg/m2, The population database consisted of 130 melphalan con- respectively. centrations. The population parameters (fixed effect: Cl and Vd There were cumulative myelo- and thrombocyto-suppres- and random effect: sigma(Cl), sigma(Vd) were as follows: Cl ϭ sions. Indeed, neutropenia and thrombocytopenia were more 168 ml/min/m2 (CV ϭ 30.6%) and Vd ϭ 13.5 liters/m2 (coef- pronounced after the first courses of melphalan. The severity ficient of variation ϭ 50.4%). Fig. 1 shows the plasma decay and the incidence of toxicity varied according to the history of curves of melphalan (plasma concentration versus time curve) previous cancer therapy. of three representative patients. The mean (Ϯ SD) values of the Anemia was dose related. In the first course of chemother- main pharmacokinetic parameters are reported in Table 4. Large apy, four grade 3 (two at 30 mg/m2 and two at 40 mg/m2) and interindividual variability of the pharmacokinetic parameters two grade 4 were observed. Thirty-four cycles (68%) were was observed. For the majority of patients, a steady state con- associated with anemia of at least grade 2, and packed red cell centration was reached about 5 h after the start of infusion infusions were given on 4, 13, and 21 occasions for 20, 30, and (extreme values: 0.039–0.122 ␮g/ml at 20 mg/m2; 0.084–0.15 40 mg/m2 dose level, respectively. ␮g/ml at 30 mg/m2; and 0.123–0.265 ␮g/ml at 40 mg/m2). A ϭ Extramedullary Toxicity. Toxicities of the three dose linear relationship was found between the dose and Css (r levels of melphalan are listed in Table 3. They were moderate, 0.57; P ϭ 0.0068) and between the dose and AUC (r ϭ 0.60, and their incidence and severity were not dose related. Indeed, P ϭ 0.0038). Normalized to a 20-mg/m2 dose, mean AUC there were only three grade 3 and one grade 4 effects noted for values showed considerable interindividual variability and over- the 50 courses of chemotherapy. The main toxicities included lapped between dose levels. They were 1.91, 1.96, and 2.54 gastrointestinal and hepatic complications. ␮g⅐h/ml, after administration of 20, 30, and 40 mg/m2, respec- Melphalan was administered 15 min after i.v. conventional tively. Despite an increase in the mean values with the doses, no ϭ antiemetic therapy (granisetron, granisetron and methylpred- significant difference occurred (P 0.148; NS). The t1/2 elim nisolone, granisetron and alizapride, or alizapride). Despite this (mean values: 40.2 min at 20 mg/m2, 55.2 min at 30 mg/m2 and treatment, nausea and vomiting were observed in 4 of 50 86.4 min at 40 mg/m2) and Vd (mean values: 10.8 liters/m2 at 20 courses. In most of the patients, these gastrointestinal compli- mg/m2, 12.5 liters/m2 at 30 mg/m2 and 16.6 liters/m2 at 40 cations were brief in duration and occurred during the treatment mg/m2) increased with dose, whereas Cl (mean values: 192 or a few hours after the infusion. ml/min/m2 at 20 mg/m2, 178 ml/min/m2 at 30 mg/m2, and 141

Fig. 1 Representative concentration-time curve (nonlinear regression fit of the data) after 24-h continuous infusion of melphalan; plasma decay curves from three representative patients. Subject 1: f, 20 mg/m2; Sub- ject 10: , 30 mg/m2; and Subject 15: F,40 mg/m2 .

Table 4 Mean (ϮSD) plasma pharmacokinetic parametersa by dose level of melphalan Dose No. of AUC Cl Vd 2 ␮ ␮ ⅐ 1 2 2 (mg/m ) patients Css ( g/ml) ( g h/ml) t ⁄2 elim (h) (ml/min/m ) (liters/m ) 20 5 0.080 Ϯ 0.034 1.91 Ϯ 0.64 0.67 Ϯ 0.31 192 Ϯ 63 13.4 Ϯ 4.8 30 9 0.121 Ϯ 0.046 2.94 Ϯ 0.85 0.92 Ϯ 0.67 178 Ϯ 38 12.3 Ϯ 6.9 [0.081 Ϯ 0.031] [1.96 Ϯ 0.57] 40 7 0.206 Ϯ 0.045 5.09 Ϯ 1.38 1.44 Ϯ 0.58 141 Ϯ 40 17.1 Ϯ 5.2 [0.097 Ϯ 0.028] [2.54 Ϯ 0.69] Pb NSc NS NS NS NS NS a 2 Css and AUC values between brackets are values normalized to a 20-mg/m administered dose. b Comparison between doses.

ml/min/m2 at 40 mg/m2) decreased; however, statistical com- delivery because of the decreased logistic complexity with at- parison of the pharmacokinetic parameters revealed no significant tendant increased patient convenience. Particularly compelling ϭ ϭ difference in the t1/2 elim (P 0.0997), Cl (P 0.148), and Vd is the schedule dependency of cytarabine cytotoxicity, in which (P ϭ 0.203; Table 4). single large bolus injections have modest antitumor activity,

No significant relationship was found between AUC or Css whereas continuous exposure or multiple smaller bolus infu- and the hematological toxicity. sions display markedly enhanced activity. Selected trials of continuous infusion of bleomycin in cervical carcinoma, vin- Tumor Response blastine in breast carcinoma, 5-fluorouracil in colon carcinoma, Disease response was determined in 20 patients. Two pa- and methotrexate in acute lymphocytic leukemia have suggested tients (10%) had a partial response (Ͼ50% reduction) of an increased antitumor activity compared with conventional bolus ovarian carcinoma and an adenocarcinoma of unknown primary infusion (21–25). In addition to therapeutic activity, several origin that has been sustained for Ͼ4 months in both patients. practical aspects of infusional chemotherapy provide potential One patient with thymoma had stable disease for a period of up advantages over bolus chemotherapy. Infusional administration to 4 months. Disease progression was observed in the other may improve the therapeutic index by decreasing gastrointesti- patients. nal side effects and cardiotoxicity associated with doxorubicin, as well as pulmonary toxicity, associated with bleomycin (26–29). DISCUSSION The alkylating agents represent a chemically heterogene- The mechanism of action (phase-specificity), pharmacoki- ous group of compounds, with a broad spectrum of applications netics (plasma half-life, Vd, and protein binding), stability in in cancer treatment (4, 30, 31). Infusional schedules for these solution, and available preclinical data predict that many cyto- agents demonstrate a clinical substantial experience and increas- toxic agents will have schedule-dependent antitumor activity ing application (cyclophosphamide and ifosfamide; Ref. 32). and toxicity. Refinement i.v. access options and ambulatory For melphalan, no study has been published with systemic infusion pumps have stimulated increased interest in infusional infusional chemotherapy. The difficulty in using melphalan

during long-term infusion was its low stability in 5% dextrose human tumor-cell proliferation in in vitro studies. Indeed, the and 0.9% sodium chloride fluids. Therefore, the manufacturer melphalan concentration that inhibited 50% of growth in human recommended a use not exceeding 1.5 h after reconstitution in myeloma 8226 cell line was 0.11 ␮g/ml for a 12-h exposure (9). 0.9% sodium chloride. However, we have recently shown that In our study, this concentration was exceeded in the plasma of the stability of melphalan can be increased using 3% sodium all of the patients after 30 and 40 mg/m2. By comparison with chloride (17). Consequently, it becomes possible to consider the the AUC observed by several authors after bolus administration administration of melphalan by continuous infusion. of 15–20 mg/m2 dose, the AUC obtained after long-term infu- Preclinical studies suggested that prolonged infusion of sion of 20 mg/m2 was about 1.5 times higher (11, 14, 35). melphalan might be more active than short infusion. Indeed, Relationships have been found between AUC and doses and Bosanquet and Bird (7), using in vitro chemosensitivity assays, between C and doses. Moreover, Cl, t elim, and Vd did not attempted to reproduce a system that mimics the action of this ss 1/2 change statistically with dose, suggesting linear kinetics. drug in vivo. This physicochemical study showed that for mel- The short t elim of melphalan, its mechanism of action, phalan a continuous drug incubation should be optimal. These 1/2 and the first results from in vitro studies allow us to think that authors suggest that an in vitro pharmacokinetic study should be undertaken to determine whether continuous exposure of mel- continuous venous infusion of melphalan may be superior to the phalan would be preferable to the i.v. bolus administration short infusion in cancer patients, but its use in clinical practice commonly used. In a recent study, we have confirmed the remains to be determined. However, although the oral route of interest of continuous infusion by in vitro experiments using administration could offer greater flexibility in terms of sched- human cancer cell lines (9). Moreover, the pharmacokinetic ule manipulation than the infusion and could increase the quality parameters and the fact that alkylating agents are phase-specific of life, systemic levels are very variable following oral admin- support continuous infusion for this drug. Brox et al. (33) istration (bioavailability, 20–80%; Refs. 3, 36, 37), and the studied the effect of concentration and duration of exposure on absorption of melphalan may be affected by food intake and the extent of melphalan-induced cross-linking in a human lym- associated drugs (14, 38). Moreover, the amount of drug intake phoblastoid cell line, RPME 6410. The S-phase block became and tablets per day and the increased risk of nausea and vom- irreversible if cells were exposed to 1 ␮g/ml melphalan for 4–6 iting at doses of about 30 mg/m2 make this administration route h. Similarly, Ross et al. (34) have shown that, in murine L1210 difficult to perform. leukemia, the extent of DNA cross-linking increased for 5 h As a conclusion to this study, we recommended a dose of after exposure to melphalan. 30 mg/m2 for Phase II trials of melphalan in 24-h continuous We undertook a Phase I study of i.v. melphalan, given for infusion. 24 h, with the aim of identifying the MTD, the dose-limiting toxicities, and the pharmacokinetic characteristics of this drug in patients with refractory cancers. In our trial, performed on a REFERENCES small group of patients, the toxicity profile of melphalan after 1. Samuels, B., and Bitran, J. D. High-dose intravenous melphalan: a long-term infusion did not differ greatly from that reported after review. J. Clin. Oncol., 13: 1786–1799, 1995. 1-h infusion (2). However, for the same total-administered-dose, 2. Sarosy, G., Leyland-Jones, B., Soochan, P., and Cheson, B. D. 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Downloaded from clincancerres.aacrjournals.org on September 26, 2021. © 2000 American Association for Cancer Research. A Phase I and Pharmacokinetic Study of Melphalan Using a 24-hour Continuous Infusion in Patients with Advanced Malignancies

Frédéric Pinguet, Stéphane Culine, Françoise Bressolle, et al.

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