703.Full.Pdf

Vol. 9, 703–710, February 2003 Clinical Cancer Research 703

Phase I Clinical and Pharmacologic Study of Weekly Cisplatin and Irinotecan Combined with Amifostine for Refractory Solid Tumors1

Abdul-Kader Souid, Ronald L. Dubowy, Conclusion: The combination of cisplatin and irinote- Susan M. Blaney, Linda Hershon, Jim Sullivan, can administered weekly for 4 weeks in children with re- Wendy D. McLeod, and Mark L. Bernstein1 fractory cancer is well tolerated. Amifostine offers some myeloprotection, likely permitting >30% dose escalation for Departments of Pediatric Hematology/Oncology, State University of irinotecan, when administered in a combination regimen New York Upstate Medical University, Syracuse, New York 13210 [A-K. S., R. L. D.]; Texas Children’s Cancer Center, Houston, Texas with cisplatin. However, effective antiemetics and calcium 77030 [S. M. B.]; Sainte-Justine Hospital, H3T 1C5, Canada [L. H., supplementation are necessary with the use of amifostine. M. L. B.]; and the Statistical Office, Children Oncology Group, Further escalation of irinotecan dosing, using these precau- Gainesville, Florida 32601 [J. S., W. D. M.] tions for amifostine administration, may be possible.

ABSTRACT INTRODUCTION Purpose: This Phase I study was designed primarily to Irinotecan (Camptosar, CPT-11, 7-ethyl-10-[4-(1-piper- determine the maximum tolerated dose (MTD) and dose- idino)-1-piperidino]carbonyloxycamptothecin) is a water-solu- limiting toxicities (DLTs) of irinotecan and cisplatin with ble derivative of camptothecin, an alkaloid extracted from the and without amifostine in children with refractory solid Chinese tree Camptotheca accuminata (1). Its therapeutic effect tumors. is mediated by the active metabolite SN-38 (7-ethyl-10- Patients and methods: Cisplatin, at a fixed dose of 30 hydroxycamptothecin), which is generated in the plasma and mg/m2, and escalating doses of irinotecan (starting dose, 40 tissues (e.g., the liver, bowel mucosa, and tumors) by the cata- mg/m2) were administered weekly for four consecutive lytic activity of carboxylesterase that cleaves the water-solubi- weeks, every 6 weeks. After the MTD of irinotecan plus lizing dipiperidino side chain (2). SN-38, in turn, interferes with cisplatin was determined, additional cohorts of patients were the nicking-ligation reaction of topoisomerase I (a nuclear en- enrolled with amifostine (825 mg/m2) support. Leukocyte zyme involved in DNA transcription, replication, and repair), DNA-platinum adducts and pharmacokinetics of cisplatin preventing DNA ligation (3). Irinotecan was approved by the and WR-1065 (amifostine-active metabolite) were also de- United States Food and Drug Administration in 1996 for termined. the treatment of colorectal cancers refractory to 5-fluorouracil. Results: Twenty-four patients received 43 courses of The drug also has a broad spectrum of activity against pediatric 2 therapy. The MTD for irinotecan administered in combina- solid tumors (4, 5). The DLTs of irinotecan are myelosuppres- tion with cisplatin (30 mg/m2) was 50 mg/m2. The DLTs of sion and diarrhea (produced by the effect of SN-38 on intestinal this combination were neutropenia and thrombocytopenia. motility; Refs. 4 and 5). High doses of loperamide control With the addition of amifostine, at an irinotecan dose of 65 diarrhea in most patients (6). mg/m2 and cisplatin dose of 30 mg/m2, the DLT was hy- Cisplatin, cis-diamminedichloroplatinum (II), exerts its an- pocalcemia. Although no objective responses were observed, titumor activity through binding to cellular DNA (7). When six patients received at least three courses of therapy. The cisplatin enters the cell, it aquates, producing cationic species amounts of platinum adducts (mean ؎ SD) were 10 ؎ 20 that bind to nitrogen atoms on the bases of DNA (8). Cisplatin molecules/106 nucleotides. The maximum plasma concentra- binding alters the structure of DNA, affects its ability to act as a template in transcription, and promotes cell death by apoptosis ؎ tions (Cmax) for free cisplatin and WR-1065 were 4.5 1.6 ␮ ϳ ؎ ␮ (9, 10). Cisplatin also has a broad spectrum of antitumor activity M and 89 10 M, respectively. The half-life (t1/2) for and is included in standard front-line treatment regimens for a ؎ free plasma cisplatin was 25.4 5.4 min. The initial t1/2 for ϳ ϳ variety of adult and pediatric solid tumors. Cisplatin toxicities plasma WR-1065 was 7 min and terminal t1/2 24 min. are cumulative. The primary DLTs of cisplatin are nephrotox- icity, peripheral neuropathy, and ototoxicity. Amifostine [WR-2721, S-2-(3-aminopropylamino)ethyl phosphorothioic acid] is used to ameliorate some renal and bone Received 7/1/02; revised 9/24/02; accepted 10/1/02. The costs of publication of this article were defrayed in part by the 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 Department of 2 The abbreviations used are: DLT, dose-limiting toxicity; ANC, abso- Pediatric Hematology/Oncology, Sainte-Justine Hospital, 3175 Chemin lute neutrophil count; Pt, platelet; G-CSF, granulocyte colony-stimulat- Cote Ste Catherine, Montreal, Quebec, Canada H3T 1C5. Phone: ing factor; SGPT, serum glutamic pyruvic transaminase; nt, nucleotide; (514) 345-4969; Fax: (514) 345-4792; E-mail: bernstm@magellan. CNS, central nervous system; SD, stable disease; MTD, maximum umontreal.ca. tolerated dose.

Table 1 Treatment strata, irinotecan dose escalation, and treatment courses Irinotecan Cisplatin No. of Total no. of Total no. of Stratum (mg/m2) (mg/m2) patients courses started courses completed I 40 30 3 6 2a (heavily pretreated without amifostine) II 40 30 6 13 12 (less heavily pretreated without amifostine) 50 30 4 6 6 65 30 6 11 8b III 65 30 5 7 6 (less heavily pretreated with amifostine) Total 24 43 34 a One course was completed at a irinotecan dose of 32 mg/m2. b Two courses were completed at a irinotecan dose of 50 mg/m2.

marrow toxicities (11). The drug is activated in the blood by tumors); (i) no anticancer therapy for Ն3 weeks before entry (6 alkaline phosphatase, producing the free thiol metabolite WR- weeks for nitrosoureas); (j) no local radiation for Ն2 weeks 1065 [WR-SH, S-2-(3 aminopropylamino)ethanethiol], which before entry; (k) no craniospinal or Ն50% pelvic radiation for enters the cell by passive diffusion. The side effects of amifos- Ն6 months before entry; (l) no autologous or allogeneic bone tine include hypotension, hypocalcemia, nausea, and vomiting marrow transplantation (without total body irradiation) for Ն6 (12). Guidelines for amifostine dosing, administration, and man- months before entry; (m) no graft-versus-host disease; (n) agement of hypocalcemia are reported (13–15). ANC Ն 1,000/mm3; hemoglobin concentration Ն 8 grams/dl; The different mechanisms of action, the lack of overlap- (o) Pt count Ն100,000/mm3;(p) bilirubin Յ 1.5 mg/dl; (q) ping DLTs, and the broad spectrum of antitumor activity re- SGPT less than or equal to twice the upper limit of normal; and sulted in clinical trials to determine the MTD and DLTs of the (r) normal serum creatinine for age, or glomerular filtration rate. combination of cisplatin and irinotecan administered to adults Specific exclusion criteria were pregnancy, breast feeding, with refractory solid tumors (16–22). These studies demon- and therapy with anticonvulsants. For less heavily pretreated strated that the combination was well tolerated and effective. patients, the exclusion criteria also included more than two The DLTs were neutropenia, diarrhea, and cisplatin neph- previous chemotherapy regimens, central axis radiation, bone ropathy. marrow involvement with cancer, and previous bone marrow Because cisplatin is widely used in pediatric tumors and the transplantation. initial results of preclinical and early Phase I clinical studies The study was approved by the institutional review board suggest that irinotecan may have antitumor activity in a variety of each participating institution. Written informed consent was of pediatric solid tumors (1), we initiated a pediatric Phase I trial obtained for each patient before study entry. of this combination with and without amifostine. Cisplatin and Pretreatment evaluation included medical history, physical irinotecan were given weekly for 4 weeks, followed by a 2-week examination, performance status, tumor size, chest roentgeno- 2 rest. The cisplatin dose was fixed at 30 mg/m , and the irino- gram, complete blood count, serum electrolytes, creatinine, cal- ϳ tecan dose was escalated in increments of 30% (20). After the cium, magnesium, phosphate, bilirubin, SGPT, total protein, MTD of cisplatin plus irinotecan was determined, additional albumin, and urinalysis. The same tests were done at least 2 cohorts of patients were enrolled with amifostine (825 mg/m ) weekly thereafter. Complete blood count was done two to three support. The study also included an estimation of the levels of times per week during myelosuppression. Tests of measurable leukocyte DNA-Pt adducts, the pharmacokinetics of cisplatin, disease, appropriate roentgenograms, bone marrow examination and the pharmacokinetics of WR-1065. (if infiltrated), and audiogram were done before and every 6 weeks during treatment. PATIENTS AND METHODS Treatment Plan. Cisplatin and irinotecan were adminis- Patient Population. Patients between 1 and 22 years of tered weekly for four consecutive weeks, every 6 weeks. age with confirmed malignant solid tumors refractory to stand- Courses were repeated every 6 weeks if there was no unaccept- ard therapy were eligible for this trial. Other eligibility criteria able toxicity or evidence of disease progression. The three included: (a) Karnofsky score Ն 50% for patients Ͼ10 years old treatment strata, irinotecan dose escalation schema, and treat- and Lansky play scale Ն 50% for patients Յ10 years old; (b) ment courses are shown in Table 1. life expectancy Ն 8 weeks; (c) Ն3rd percentile weight for Cisplatin was administered i.v. at a fixed dose of 30 mg/m2 height; (d) serum albumin Ն 2.5 grams %; (e) recovery from (mixed in 100 ml/m2 0.9% NaCl) over 60 min after 2 h of acute toxicity of previous therapy; (f) no significant systemic prehydration with 600 ml/m2 5% dextrose in 0.9% NaCl with 10 illness (e.g., uncontrolled infection); (g) no growth factors for meq KCl/liter. Irinotecan was administered as a 90-min i.v. Ն1 week before entry; (h) stable or decreasing doses of dexa- infusion immediately after cisplatin infusion. The starting dose methasone for Ն2 weeks before entry (for patients with CNS of irinotecan was 40 mg/m2. The dosage was increased in

subsequent cohorts to 50 and 65 mg/m2. After administration of the following adverse effects in 2 of 3–6 patients at a given dose irinotecan, patients received two additional hours of hydration level: (a) any grade III or IV nonhematologic toxicity with the with 600 ml/m2 5% dextrose in 0.45% NaCl with 10 meq specific exception of grade III nausea and vomiting, an elevated KCl/liter. SGPT that returned to grade Յ 1 before the next course, and Amifostine (825 mg/m2, mixed in 100 ml/m2 0.9% NaCl) grade III fever or infection; (b) grade IV neutropenia (ANC Ͻ was infused i.v. over 15 min immediately before cisplatin in the 500/mm3) for Ͼ7 days; (c) grade IV thrombocytopenia (Pt cohort of patients enrolled after determination of the MTD for count Ͻ 10,000/mm3) for Ͼ7 days or requiring at least two irinotecan administered with the fixed dose of cisplatin. transfusions in 7 days or delaying treatment Ն 14 days; (d)an Criteria for starting a subsequent course of therapy in- inability to complete the first four treatment doses in 29 days; or cluded an ANC Ն 1,000/mm3, Pt count Ն 100,000/mm3,he- (e) the failure to recover from toxicity by day 43. moglobin concentration Ն 8 grams/dl, normal serum creatinine Three patients were treated at each dose level. Up to 3 for age, total bilirubin Յ 1.5 mg/dl, and SGPT less than or equal additional patients were treated at the same dose level if one of to twice the normal upper limit. Treatment doses within a course the 3 patients experienced DLT. A dose escalation was allowed of therapy were held for any of the following: (a) ANC Յ if none of the 3 or 1 of the 6 patients experienced DLT during 500/mm3;(b) Pt count Յ 50,000/mm3;(c) serum creatinine Ն the first course of therapy. The DLTs were evaluated for all 150% of pretreatment value; or (d) any grade 2 or greater treatment cycles, although determination of MTD was per- nonhematologic toxicity. Resumption of an interrupted course formed based on toxicities during the first course only. was permitted at a reduced irinotecan dosage when the toxicity The MTD was defined as the dose level immediately below resolved and the criteria for starting a new treatment course that at which 2 of 3–6 patients experienced DLT. No intrapa- were met. In subsequent cycles of therapy, the irinotecan dosage tient dose escalation was allowed. The MTD was defined in both was reduced to the previous dose level for an ANC Յ 500/mm3 heavily pretreated and less heavily pretreated patients. After the for Ͼ7 days, Pt count Ͻ 20,000/mm3 for Ͼ7 days, or reversible MTD for irinotecan was determined, the amifostine stratum nonhematologic DLTs. (stratum III) was opened at an irinotecan dose of 65 mg/m2 Supportive Care Measures. All patients were premed- (Table 1). Patients in this stratum were required to be less icated with ondansetron (0.15 mg/kg i.v. every 4 h ϫ 2 or 0.45 heavily pretreated. mg/kg i.v. ϫ 1). For patients with significant nausea and vom- Response Criteria. The criteria for response were: (a) iting, diphenhydramine (0.5–1 mg/kg, maximum 50 mg) and complete response, resolution of all measurable tumors, and no ranitidine (1 mg/kg, maximum 50 mg) were recommended appearance of new lesions for 3 weeks; (b) partial response, before amifostine infusion. Dexamethasone was not allowed as Ն50% decrease in the sum of products of maximum perpendic- an antiemetic agent. Patients also received p.o. magnesium ular diameters of all measurable lesions, no evidence of pro- gluconate (3 grams/m2/day in three divided doses) or i.v. mag- gression in any lesion, and no new lesions for 3 weeks; (c) SD, nesium sulfate (30 mg/kg/24 h). Pneumocystis carinii prophy- no evidence of progression in any lesion, and no new lesions for laxis [trimethoprim (150 mg/m2/day) plus sulfamethoxizole 3 weeks; (d) progressive disease, Ն25% increase in the sum of (750 mg/m2/day), pentamidine, or dapsone] was recommended. products of maximum perpendicular diameters of any measur- Loperamide (1 mg followed by 0.5 mg every 2 h for able lesions, and/or the appearance of new lesions. children 1–6 years old, 2 mg followed by 1 mg every 2 h Leukocyte DNA-Pt Adducts. Leukocyte DNA-Pt ad- for children 6–8 years old, 3 mg followed by 1.5 mg every ducts were determined on day 1 of the first course. Blood 2 h for children 8–12 years old, and 4 mg followed by 2 mg samples (ϳ10 ml/time point from patients Ͼ10 kg and ϳ5ml every 2 h for children Ͼ12 years old) was administered at the from patients Յ 10 kg) were drawn into EDTA tubes before first sign of poorly formed or loose stool or at the earliest onset cisplatin infusion, then at 0, 1, 2, and 4 h from the end of of bowel movements that were more frequent than expected. cisplatin infusion. Samples were centrifuged immediately at Patients were allowed to stop loperamide only after being diar- 4°C, and the plasma was removed. The blood cell pellets (con- rhea free for Ն12 h. Early diarrhea (within the first 12 h of taining the buffy coats) were stored at Ϫ20°C (storage at Ϫ70°C irinotecan) was treated with atropine (0.01 mg/kg, maximum of instead of Ϫ20°C gave the same yield; data not shown), shipped 0.4 mg/dose). on dry ice, and processed immediately on arrival. Each sample In patients who received amifostine, calcium levels (total was diluted with distilled water to 50 ml, mixed by inversions, and ionized) were monitored, and calcium was administered if placed on ice for ϳ5 min, and centrifuged at 2000 ϫ g for 10 amifostine-associated hypocalcemia was noted. Oral calcium min. The supernatants were canned, and the procedure was carbonate, 20 mg/kg elemental calcium every 8 h ϫ 3 starting repeated twice. As described previously, the DNA was extracted the night before amifostine, was recommended for patients with from the leukocyte pellets, and atomic absorption spectroscopy precarious nutritional status, borderline pretherapy calcium lev- was used to quantitate the Pt adducts in the DNA (23). els, or preexisting renal tubular injury. Calcium supplements Cisplatin Pharmacokinetics. Cisplatin pharmacokinet- were given to all patients with hypocalcemia. ics were determined on day 8 of the first course. Blood samples G-CSF was allowed only for patients with ANCs Յ 500/ (1 ml each) for plasma cisplatin determinations were drawn into mm3 and documented bacterial infections. Other anticancer EDTA tubes before cisplatin infusion, then at 0, 15, 30, 45, 60, therapy was not allowed on the study. and 90 min from the end of cisplatin infusion. The samples were Definitions of DLT and MTD. Toxicities were graded centrifuged immediately at 4°C, and aliquots of the plasma were according to the Common Toxicity Criteria, version 2.0 (NIH, stored at Ϫ20°C. The remaining plasma was centrifuged in an National Cancer Institute, 1999). A DLT was defined as any of Amicon Centrifree micropartition unit (30,000 molecular weight

Table 2 Patient characteristics (n ϭ 24) Characteristic Male/female 10/14 Age (years) Median 15 Range 4–21 Performance status 90–100 15 70–89 2 50–69 3 Prior therapy Chemotherapy ϩ radiation 12 Chemotherapy only 9 Chemotherapy ϩ radiation ϩ BMTa 2 Radiation only 1 Diagnoses Fig. 1 The time course of total (ࡗ) and free (F) plasma cisplatin Non-CNS tumors levels for patient 4. Ewing’s sarcoma 7 Osteogenic sarcoma 4 Rhabdomyosarcoma 3 Neuroblastoma 1 Chondrosarcoma 1 Hepatocellular carcinoma 1 CNS tumors Ependymoma 4 Brain stem glioma 2 Medulloblastoma 1 No. of course per patient Median 1 Range 1–4 a BMT, bone marrow transplantation.

logarithm of drug concentration in ␮M versus time in minutes), as shown in Figs. 1 and 2.

Fig. 2 The time course of plasma (f) and RBC (F) WR-1065 levels for patient 23. RESULTS Between December 1999 and June 2001, 43 courses of therapy were initiated in the 24 patients who participated in this trial. Thirty-four (79%) of the 43 courses were completed as cutoff, catalogue 4104; Millipore, Billerica, MA) in a fixed- planned (Table 1). Six courses (14%) were stopped early be- angle rotor (4°C, 2,000 ϫ g) for 1 h. The ultrafilterates were cause of hematologic toxicity (five during the first course and stored at Ϫ20°C, shipped on dry ice, and analyzed for cisplatin one during a subsequent course), one (2%) because of progres- content immediately on arrival using atomic absorption spec- sive disease, one (2%) to allow for needed surgery, and one troscopy as described previously (23). (2%) per the patient’s wish. All patients were assessable for Amifostine Pharmacokinetics. Amifostine pharmacoki- toxicity and response. Patient characteristics are shown in Table netics were determined on day 14 of the first course. Blood 2, and the DLTs in the first course are shown in Table 3. samples (1 ml each) for amifostine metabolites were drawn into Cisplatin Plus Irinotecan without Amifostine. Dose- EDTA tubes that contained 10 mM (final concentration) mono- limiting thrombocytopenia and neutropenia occurred in 2 of the bromobimane before amifostine and then at 0, 1, 2.5, 5, 10, 15, first 3 patients enrolled at the first irinotecan dose level (Table 30, 60, and 120 min from the end of amifostine infusion. The 3). All 3 patients were heavily pretreated, and thus the MTD of samples were mixed by inversions for 3 min, stored at 4°C, irinotecan was exceeded in heavily pretreated patients at 40 shipped on wet ice, and processed immediately on arrival. A mg/m2. Patient accrual was subsequently limited to less heavily high-performance liquid chromatography technique described pretreated patients (stratum II). previously was used to quantitate amifostine metabolites (WR- Six less heavily pretreated patients were subsequently 1065 and its disulfide forms) in both the plasma and RBCs treated at the first irinotecan dose level (40 mg/m2), 5 of whom (24–26). completed the first course. One patient experienced dose-limit- Pharmacokinetic Analyses. Pharmacokinetic analyses ing thrombocytopenia (Table 3), and 1 had hypomagnesemia for nonprotein-bound (free) cisplatin and WR-1065 were per- that responded to magnesium supplementation. formed using a nonlinear estimation program, Nonline (Statis- Escalation in the less heavily pretreated patients proceeded 2 tical Consultants, Inc., Lexington, NY). The half-life (t1/2) was to the second irinotecan dose level (50 mg/m ). Four patients calculated by ln2/k, when k was the first-order rate constant for were accrued to this dose level, and all were able to complete the the dug decay (i.e., k was the slope of the plot of natural first course without DLT (Table 3).

Table 3 DLTs in the first course at each irinotecan dose level Irinotecan Total no. of No. of patients Stratum (mg/m2) patients with DLT DLTs I 40 3 2 Thrombocytopenia (heavily pretreated and neutropeniaa without amifostine) II 40 6 1 Thrombocytopeniaa (less heavily pretreated without amifostine) 50 4 0 None 65 6 2 Thrombocytopenia and neutropeniaa III 65 5 2 Hypocalcemiab (less heavily pretreated with amifostine) a Patients were unable to complete four treatment doses in 29 days because of the hematologic toxicities. b One patient had a grade 4 hypocalcemia (serum calcium decreased from 9.8 to 4 mg/dL) and one a grade 3 hypocalcemia (serum calcium decreased from 9.8 to 6.9 mg/dL and was associated with a serum albumin of 2.9 g/dL).

Escalation in the less heavily pretreated patients proceeded Table 4 Patients with stable disease by tumor type 2 to the third irinotecan dose level (65 mg/m ). Six patients were No. of patients with SD/ Median no. of accrued to this dose level, of whom 1 had dose-limiting neutro- Tumor type total no. of patients courses with SD penia and another dose-limiting thrombocytopenia (Table 3). Ewing sarcoma 4/7 2 Grade 4 nausea and vomiting occurred in 1 patient, necessitating Osteogenic sarcoma 0/4 0 hospitalization for rehydration. Ependymoma 3/4 2 Thus, the MTD for irinotecan administered in combination Rhabdomyosarcoma 3/3 1.5 with a fixed dose of cisplatin (30 mg/m2) weekly ϫ 4 without Brain stem glioma 1/2 1 2 Medulloblastoma 1/1 3 amifostine was 50 mg/m /dose for less heavily pretreated pa- Neuroblastoma 1/1 1 tients. No formal MTD was established for heavily pretreated Chondrosarcoma 1/1 1 patients, although the opening dose level of 40 mg/m2 irinotecan Hepatocellular carcinoma 1/1 3 was beyond MTD. Total 15/24 Cisplatin Plus Irinotecan with Amifostine. In an at- tempt to further escalate the irinotecan dosage, concomitant amifostine, at a fixed dose of 825 mg/m2 (stratum III), was added to the combination regimen. Five patients were enrolled Response. Although no objective responses were ob- at the 65 mg/m2 irinotecan dose level; however, 1 patient served, 6 patients received at least three courses (ϳ18 weeks) of refused further treatment before completing an entire course. Six therapy, including 2 patients with Ewing’s sarcoma and 1 pa- courses of therapy were initiated in the remaining 4 patients; 2 tient each with rhabdomyosarcoma, medulloblastoma, and hep- patients experienced amifostine-related hypocalcemia (Table 3). atocellular carcinoma. SD was present in 15 of 24 patients One patient had a grade 4 hypocalcemia ϳ22 h after the first (ϳ63%) and 28 of the 43 courses (65%; Table 4). amifostine dose and responded to calcium supplements. Another Leukocyte DNA-Pt Adducts. The leukocyte DNA-Pt patient had a grade 3 hypocalcemia, which also responded to adduct levels are shown in Table 5. Remarkable variability calcium supplements. Grade Ն2 hypocalcemia occurred in five existed among the 15 patients studied, ranging from an unde- of the seven courses. The hypocalcemia was asymptomatic in all tectable level (4 patients) to 78 Pt molecules per 106 nt (patient Ն patients. Nausea and vomiting (grade 2) occurred in six (85%) 2, who had bilateral hydronephrosis and t1/2 for free plasma of the seven courses, necessitating hospitalization for rehydra- cisplatin of 43 min). The levels of Pt adducts did not correlate tion in 1 patient. Asymptomatic hypokalemia (grade 3) occurred with response or toxicity. in 1 patient and was associated with grade I diarrhea and line Cisplatin Pharmacokinetics. The Cmax for total plasma infection. cisplatin was [mean Ϯ SD (n)] 7 Ϯ 3.6(10) ␮M and nonprotein- 2 In contrast to toxicities of cisplatin (30 mg/m ) plus irino- bound (free) 4.7 Ϯ 1.6(19) ␮M (i.e., ϳ65% of the total). The free tecan (65 mg/m2) without amifostine, there were no dose- plasma cisplatin had a single exponential decay in each patient Ϯ limiting hematologic toxicities observed with concomitant ami- [t/12, 25.4 5.4(19) min] (Table 5). In contrast, the total plasma fostine support. None of the seven courses were associated with cisplatin had a multiple exponential decay. The time course of an ANC Ͻ 400/mm3 or a Pt count Ͻ 40 ϫ 103/mm3. total and free plasma cisplatin levels for patient 4 is shown in Diarrhea. Diarrhea (grade Յ3) occurred in 50% of the Fig. 1. patients. Five patients received loperamide alone (1–4 days) and In patient 2, the t1/2 for free plasma cisplatin was 43 min, three loperamide (2–12 days) plus atropine (2–4 days). Two which correlated with her bilateral hydronephrosis and high patients were hospitalized for the diarrhea and one received level of leukocyte DNA-Pt adducts (78 Pt molecules/106 nt; Sandostatin (octreotide acetate). Table 5). Thus, changes in renal function have an important

Table 5 Nonprotein-bound (free) and total plasma cisplatin concentrations and amounts of leukocyte DNA-Pt adductsa Nonprotein-bound (free) plasma cisplatin Total plasma cisplatin Leukocyte DNA-Pt adductsb c ␮ ␮ 6 Patient no. Cmax ( M) t1/2 (min) Cmax ( M) Pt molecules/10 nt 1 5.8 27 13 2 5.0 43d 78d 3 3.2 25 17 4 4.5 22 3.4 8 5 4.5 23 1 6 3.8 24 4.7 4 7 3.1 28 7.3 NDe 8 8.4 20 ND 9 3.6 30 9.3 3 10 4.5 21 5.4 0.1f 12 6.3 21 13 2.0 21 5.1 16 5.6 23 6 18 5.1 24 5 19 4.1 33 9.0 20 4.5 25 ND 22 6.6 21 15.1 7 23 1.9g 28 3.2g 24 3.3 24 7.3 10 Mean Ϯ SD 4.5 Ϯ 1.6 25.4 Ϯ 5.4 7.0 Ϯ 3.6 10 Ϯ 20 a Calculation of Pt adducts is based on 1 pg Pt/␮g DNA ϭ 5.13 femtomoles Pt/␮g DNA (Pt M.W., 195.078) and 1 femtomole Pt/␮g DNA ϭ ϳ0.34 Pt molecules/106 nt (average nt M.W., ϳ343 g molϪ1; Ref. 23). b Maximum Pt adduct values in the first 4 h after cisplatin infusions. c Pt concentrations in the ultrafiltrates at the end of cisplatin infusions. d Patient had bilateral hydronephrosis and borderline glomerular filtration rate. e ND, nondetected. f Lowest limit of detection. g 5 min postcisplatin infusion.

influence on cisplatin pharmacokinetics and pharmacodynam- notecan/cisplatin combination, although the irinotecan dose was ϳ ␮ ics. The Cmax for total plasma cisplatin of 7 M (Table 5) 30% greater than the MTD without amifostine support (Table represents only ϳ7% of the administered dose (calculated using 3). This result suggests that the addition of amifostine to the cisplatin dose of ϳ100 ␮mol/m2 and plasma volume of ϳ1 combination may allow for further irinotecan dose escalation. 2 liter/m ), confirming the rapid distribution and elimination of This finding is in contrast to the results of a previous pediatric cisplatin. Phase I trial in which higher doses of amifostine (Յ2700 mg/ Amifostine Pharmacokinetics. WR-1065 peaked in the m2) did not allow for dose escalation of melphalan beyond the plasma and RBC at the end of amifostine infusions with Cmax of MTD (12). Thus, the clinical efficacy of amifostine may depend ␮ 82–96 and 68–135 M, respectively. WR-1065 also decayed on both the type and dose of chemotherapy. Unfortunately, in from both compartments with similar initial (t ,6–8 min) and 1/2␣ this trial, a dose-limiting, amifostine-related toxicity (hypocal- terminal (t ,20–28 min) half-lives (Table 6). The time course 1/2␤ cemia) prevented further escalation of the irinotecan dose. How- of plasma and RBC WR-1065 levels for patient 23 is shown in ever, it is quite possible that a lower amifostine dose or a more Fig. 2. aggressive supportive care regimen may ameliorate or prevent some of the amifostine adverse effects. The amifostine dose in DISCUSSION this trial (825 mg/m2) is based on our recently completed study This is the first Phase I pediatric trial to evaluate the in children with metastatic Ewing sarcoma (Pediatric Oncology combination of cisplatin and irinotecan with and without ami- Group 9457) and is in the range of single doses reported previ- fostine support. The DLT of cisplatin and irinotecan adminis- ously (most frequently between 740 and 910 mg/m2) given in tered weekly for four consecutive weeks every 6 weeks, in both association with chemotherapy (25, 26). A new Phase I trial, heavily and less heavily pretreated patients, was myelosuppression (Table 3). The MTD of irinotecan when administered in however, would need to be designed to determine the appropri- combination with cisplatin (30 mg/m2) was Ͻ40 mg/m2 for ate supportive regimen for amifostine, which might allow fur- heavily pretreated patients and 50 mg/m2 for less heavily pre- ther dose escalation of the irinotecan/cisplatin combination. treated patients. These results are similar to the recent adult trial, Without amifostine, hematologic DLTs (neutropenia and showing the MTD for irinotecan in patients treated previously to thrombocytopenia) dominated in all courses (Table 3). Grade 3 be 50 mg/m2 and in chemotherapy-naive patients, 65 mg/m2; the Ն3 neutropenia (ANC Ͻ 1,000/mm ) was present in 20 (55%) DLT in both groups was neutropenia (20). of the 36 courses and thrombocytopenia (Pt count Ͻ 50,000/ Interestingly, with the addition of amifostine, there was no mm3) in 11 (30%) of the 36 courses. Although neutropenia was dose-limiting myelosuppression after administration of the iri- frequent, it was not complicated by fever. G-CSF was used only

Table 6 Plasma and RBC levels of amifostine metabolites REFERENCES Free thiol metabolite 1. Rothenberg, M. L. The current status of irinotecan (CPT-11) in the plus its low United States. Ann. N. Y. Acad. Sci., 803: 272–281, 1996. Free thiol metabolite molecular weight 2. Rivory, L. P., Bowles, M. R., Robert, J., and Pond, S. M. Conversion (WR-1065) disulfides of irinotecan (CPT-11) to its active metabolite, 7-ethyl-10-hydroxycamptothecin (SN-38), by human liver carboxylesterase. Biochem. C t t C t t max 1/2␣ 1/2␤ max 1/2␣ 1/2␤ Pharmacol., 52: 1103–1111, 1996. Patient no. ␮M min min ␮M min min 3. Wang, X., Wang L-K., Kingsbury, W. D., Johnson, R. K., and Hecht, 20 plasma 107 8 S. M. Differential effects of camptothecin derivatives on topoisomerase 22 RBC 68 6 85 3 I-mediated DNA structure modification. Biochemistry, 37: 9399–9408, 23 plasma RBC 96 7 23 87 12 22 1998. 135 8 20 143 7 22 24 plasma RBC 82 8 28 4. Turner, C. D., Gururangan, S., Eastwood, J., Bottom, K., Watral, M., 90 95 27 Beason, R., McLendon, R. E., Friedman, A. H., Tourt-Uhlig, S., Miller, L. L., and Friedman, H. S. Phase II study of irinotecan (CPT-11) in children with high-risk malignant brain tumors: the Duke experience. Neuro-Oncology, 4: 102–108, 2002. 5. Ma, M. K., Zamboni, W. C., Radomski, K. M., Furman, W. L., Santana, V. M., Houghton, P. J., Hanna, S. K., Smith, A. K., and once, briefly and in error. Thus, G-CSF was not required for this Stewart, C. F. Pharmacokinetics of irinotecan and its metabolites SN-38 regimen. and APC in children with recurrent solid tumors after protracted low- With amifostine, nonhematologic DLT (hypocalcemia) dose irinotecan. Clin. Cancer Res., 6: 813–819, 2000. dominated at an irinotecan dose of 65 mg/m2 (Table 3). Nev- 6. Abigerges, D., Armand J-P., Chabot, G. G., De Costa, L., Fadel, E., ertheless, grade Ն3 myelosuppression was seen in one (15%) of Cote, C., Herait, P., and Gandia D. Irinotecan (CPT-11) high-dose escalation using intensive high-dose loperamide to control diarrhea. the seven courses. Frequent calcium monitoring and adequate J. Natl. Cancer Inst. (Bethesda), 86: 446–449, 1994. calcium supplementation are necessary for the prevention and 7. Gelasco, A., and Lippard S. J. Anticancer activity of cisplatin and treatment of amifostine-related hypocalcemia, especially in pa- related compounds. Top. Biol. Inorg. Chem., 1: 1–43, 1999. tients receiving cisplatin, because cisplatin may itself induce 8. Fichtinger-Schepman, A. M. J., van der Velde-Visser, S. D., van renal tubular injury. Dijk-Knijnenburg, H. C. M., van Oosterom, A. T., Baan, R. A., and As shown here (Table 5) and demonstrated in other studies, Berends, F. Kinetics of the formation and removal of cisplatin-DNA adducts in blood cells and tumor tissue of cancer patients receiving there is wide variation in the amount of leukocyte DNA-Pt chemotherapy: comparison with in vitro adduct formation. Cancer Res., adduct levels among patients (27–33). We reported recently that 50: 7887–7894, 1990. the rates of adduct formation and repair are rapid, and thus only 9. Bellon, S., Coleman, J., and Lippard, S. J. DNA unwinding produced methods that assure rapid stabilization of the adducts should be by site-specific intrastrand cross-links of the antitumor drug cis-diam- used (23). minedichloroplatinum (II). Biochemistry, 25: 8026–8035, 1991. Data describing the pharmacokinetic disposition of cispla- 10. Chu, G. Cellular responses to cisplatin. The roles of DNA-binding 2 proteins and repair. J. Biol. Chem., 269: 787–790, 1994. tin administered at conventional doses, e.g., 20–40 mg/m over 11. Treskes, M., and van der Vijgh, W. J. F. WR2721 as a modulator of 30–60 min, in children are lacking. The pharmacokinetic pa- cisplatin- and carboplatin-induced side effects in comparison with other rameters of cisplatin in this trial (Table 5) are similar to those chemoprotective agents: a molecular approach. Cancer Chemother. reported in 7 adult patients who received 40 mg/m2 cisplatin Pharmacol., 33: 93–106, 1993. ϳ ϳ ␮ 12. Adamson, P. C., Balis, F. M., Belasco, J. E., Lange, B., Berg, S. L., over 30 min (Cmax for free plasma cisplatin of 9 M and t1/2 Ϯ Blaney, S. M., Craig, C., and Poplack, D. G. A phase I trial of amifostine of 30 3.4 min; Ref. 32). (WR-2721) and melphalan in children with refractory cancer. Cancer Neither the cisplatin pharmacokinetics nor the Pt adducts Res., 55: 4069–4072, 1995. appear to be altered by the amifostine treatment. These findings 13. Dorr, R. T., and Homes, B. C. Dosing considerations with amifos- are consistent with other recent studies (23, 33). tine: a review of the literature and clinical experience. Semin. Oncol., 26 WR-1065 peaked in the plasma and RBC at the end of (Suppl. 2): 108–119, 1999. amifostine infusion with similar concentrations (Table 6). Free 14. Schuchter, L. M. Guidelines for the administration of amifostine. Semin. Oncol., 23 (Suppl. 8): 40–43, 1996. thiol metabolites were rapidly formed from the parent drug and 15. Wadler, S., Haynes, H., Beitler, J. J., Goldberg, G., Holland, J. F., equally distributed between the extra and intracellular compart- Hochster, H., Bruckner, H., Mandeli, J., Smith, H., and Runowiscz C. ments. Moreover, the decay rates for WR-1065 in both com- Management of hypocalcemic effects of WR2721 administered on a daily times five schedule with cisplatin and radiation therapy. J. Clin. partments were similar (t1/2␣,6–8 min and t1/2␤,20–28 min; Table 6 and Fig. 1). Detectable levels of WR-1065 and its low Oncol., 11: 1517–1522, 1993. molecular weight disulfides were present in the plasma and 16. Masuda, N., Fukuoka, M., Takada, M., Kusunoki, Y., Negoro, S., ϳ Matsui, K., Kudoh, S., Takifuji, N., Nakagawa, K., and Kishimoto, S. RBC at 2 h after WR-2721 infusion (Fig. 2). These results are CPT-11 in combination with cisplatin for advanced non-small-cell lung similar to previous reports in patients with Ewing sarcoma who cancer. J. Clin. Oncol., 10: 1775–1780, 1992. received WR-2721 and mesna (25, 26). 17. Masuda, N., Fukuoka, M., Kudoh, S., Kusunoki, Y., Matsui, K., Although we observed no objective responses, 25% of the Nakagawa, K., Hirashima, T., Tamanoi, M., Nitta, T., Yana, T., et al. children enrolled on the trial had evidence of disease stabiliza- Phase I study of irinotecan and cisplatin with granulocyte colony- Ͼ stimulating factor support for advanced non-small-cell lung cancer. tion for 4 months. Thus, consideration should to given to J. Clin. Oncol., 12: 90–96, 1994. evaluate the antitumor activity of the combination in children 18. Shinkai, T., Arioka, H., Kunikane, H., Eguchi, K., Sasaki, Y., with refractory malignancies (34). Tamura, T., Ohe, Y., Oshita, F., Nishio, M., and Karato, A. Phase I

clinical trial of irinotecan (CPT-11), 7-ethyl-10-[4-(1-piperidino)-1- 26. Souid, A-K., Fahey, R. C., Aktas, M. K., Sayin, O. A., Karjoo, S., piperidino]carbonyloxy-camptothecin, and cisplatin in combination Newton, G. L., Sadowitz, P. D., Dubowy, R. L., and Bernstein, M. L. with fixed dose of vindesine in advanced non-small cell lung cancer. Blood thiols following amifostine and mesna infusions, a Pediatric Cancer Res., 54: 2636–2642, 1994. Oncology Group study. Drug Metab. Dispos., 29: 1460–1466, 2001. 19. Kobayashi, K., Shinbara, A., Kamimura, M., Takeda, Y., Kudo, K., 27. Veal, G. J., Dias, C., Price, L., Parry, A., Errington, J., Hale, J., Kabe, J., Hibino, S., Hino, M., Shibuya, M., and Kudoh, S. Irinotecan Pearson, A. D. J., Boddy, A. V., Newell, D. R., and Tilby, M. J. (CPT-11) in combination with weekly administration of cisplatin Influence of cellular factors and pharmacokinetics on the formation of (CDDP) for non-small-cell lung cancer. Cancer Chemother. Pharmacol., platinum-DNA adducts in leukocytes of children receiving cisplatin 42: 53–58, 1998. therapy. Clin. Cancer Res., 7: 2205–2212, 2001. 20. Saltz, L. B., Spriggs, D., Schaaf, L. J., Schwartz, G. K., Ilson, D., 28. Reed, E., Ozols, R., Tarone, R., Yuspa, S. H., and Poirier, M. C. Kemeny, N., Kanowitz, J., Steger, C., Eng, M., Albanese, P., Semple, Platinum-DNA adducts in leukocyte DNA correlate with disease re- D., Hanover, C. K., Elfring, G. L., Miller, L. L., and Kelson, D. Phase sponse in ovarian cancer patients receiving platinum-based chemother- I clinical and pharmacologic study of weekly cisplatin combined with apy. Proc. Natl. Acad. Sci. USA, 84: 5024–5028, 1987. weekly irinotecan in patients with advanced solid tumors. J. Clin. 29. Motzer, R. J., Reed, R. J., Perera, F., Tang, D., Shamkhani, H., Oncol., 16: 3858–3865, 1998. Poirier, M. C., Tsai, W. Y., Parker, R. J., and Bosl, G. J. Platinum-DNA 21. De Jonge, M. J., Sparreboom, A., Planting, A. S., van der Burg, adducts assayed in leukocytes of patients with germ cell tumors meas- M. E., de Boer-Dennert, M. M., ter Steeg, J., Jacques, C., and Verweij, ured by atomic absorbance spectrometry and enzyme-linked immu- J. Phase I study of 3-week schedule of irinotecan combined with nosorbent assay. Cancer (Phila.), 73: 2843–2852, 1994. cisplatin in patients with advanced solid tumors. J. Clin. Oncol., 18: 30. Schellens, J. H. M., Ma, J., Planting, A. S., van der Burg, M. E., van 187–194, 2000. Meerten, E., de Boer-Dennert, M., Schmitz, P. I., Stoter, G., and 22. De Jonge, M. J. A., Verweij, J., de Brujin, P., Brouwer, E., Math- Verweij, J. Relationship between the exposure to cisplatin. DNA-adduct ijssen, R. H., van Alphen, R. J., de Boer-Dennert, M. M., Vernillet, L., formation in leucocytes and tumor response in patients with solid Jacques, C., and Sparreboom, A. Pharmacokinetic, metabolic, and phar- tumours. Br. J. Cancer, 73: 1569–1575, 1996. macodynamic profiles in a dose-escalating study of irinotecan and 31. Ma, J., Verweij, J., Plating, A., De Boer-Dennert, M., Van Ingen, cisplatin. J. Clin. Oncol., 18: 195–203, 2000. H. E., van der Burg, M. E., Stoter, G., and Schellens, J. H. Current 23. Sadowitz, P. D., Hubbard, B. A., Dabrowiak, J. C., Goodisman, J., sample handling methods for measurement of platinum-DNA adducts in Tacka, K. A., Atlas, M. K., Cunningham, M. J., Dubowy, R. L., and leucocytes in man lead to discrepant results in DNA adducts levels and Souid, A. K. Kinetics of cisplatin binding to cellular DNA and modu- DNA repair. Br. J. Cancer, 71: 512–517, 1995. lations by thiol-blocking agents and thiol drugs. Drug Metab. Dispos., 32. Corden, B. J., Fine, R. L., Ozols, R. F., and Collins, J. M. Clinical 30: 183–190, 2002. pharmacology of high-dose cisplatin. Cancer Chemother. Pharmacol., 24. Souid, A. K., Newton, G. L., Dubowy, R. L., Fahey, R. C., and 14: 38–41, 1985. Bernstein, M. L. Determination of the chemoprotective agent WR-2721 33. Korst, A. E., Boven, E., van der Sterre, M. L., Fichtinger-Shepman, (amifostine. Ethyol) and metabolites in human blood using monobro- A. M., and van der Vijgh, W. J. Pharmacokinetics of cisplatin with and mobimane fluorescent labeling and high-performance liquid chromatog- without amifostine in tumor-bearing nude mice. Eur. J. Cancer, 34: raphy. Cancer Chemother. Pharmacol., 42: 400–406, 1998. 412–416, 1998. 25. Souid, A. K., Fahey, R. C., Dubowy, R. L., Newton, G. L., and 34. Noda, K., Nishiwaki, Y., Kawahara, M., Negoro, S., Sugiura, T., Bernstein, M. L. WR-2721 (amifostine) infusion in patients with Ew- Yokoyama, A., Fukuoka, M., Mori, K., Watanabe, K., Tamura, T., ing’s sarcoma receiving ifosfamide and cyclophosphamide with mesna: Yamamoto, S., and Saijo, N. Irinotecan plus cisplatin compared with drug and thiol levels in plasma and blood cells, a Pediatric Oncology etoposide plus cisplatin for extensive small-cell lung cancer. N. Engl. Group study. Cancer Chemother. Pharmacol., 44: 498–504, 1999. J. Med., 346: 85–91, 2002.

Downloaded from clincancerres.aacrjournals.org on September 27, 2021. © 2003 American Association for Cancer Research. Phase I Clinical and Pharmacologic Study of Weekly Cisplatin and Irinotecan Combined with Amifostine for Refractory Solid Tumors

Abdul-Kader Souid, Ronald L. Dubowy, Susan M. Blaney, et al.

Clin Cancer Res 2003;9:703-710.

Updated version Access the most recent version of this article at: http://clincancerres.aacrjournals.org/content/9/2/703

Cited articles This article cites 34 articles, 15 of which you can access for free at: http://clincancerres.aacrjournals.org/content/9/2/703.full#ref-list-1

Citing articles This article has been cited by 2 HighWire-hosted articles. Access the articles at: http://clincancerres.aacrjournals.org/content/9/2/703.full#related-urls

E-mail alerts Sign up to receive free email-alerts related to this article or journal.

Reprints and To order reprints of this article or to subscribe to the journal, contact the AACR Publications Subscriptions Department at [email protected].

Permissions To request permission to re-use all or part of this article, use this link http://clincancerres.aacrjournals.org/content/9/2/703. Click on "Request Permissions" which will take you to the Copyright Clearance Center's (CCC) Rightslink site.