A Phase I Pharmacokinetic and Pharmacodynamic Study Of

Published OnlineFirst August 2, 2011; DOI: 10.1158/1078-0432.CCR-10-3336

Clinical Cancer Cancer Therapy: Clinical Research

A Phase I Pharmacokinetic and Pharmacodynamic Study of Dalotuzumab (MK-0646), an Anti-Insulin-like Growth Factor-1 Receptor Monoclonal Antibody, in Patients with Advanced Solid Tumors

Francesco Atzori1, Josep Tabernero1, Andres Cervantes3, Ludmila Prudkin1, Jordi Andreu1, Edith Rodríguez-Braun3, Amparo Domingo3, Jorge Guijarro3, Cristina Gamez2, Jordi Rodon1, Serena Di Cosimo1, Holly Brown4, Jason Clark4, James S. Hardwick4, Robert A. Beckman4, William D. Hanley4, Karl Hsu4, Emiliano Calvo1, Susana Rosello3, Ronald B. Langdon4, and Jose Baselga1,5

Abstract Purpose: Insulin-like growth factor-1 receptor (IGF-1R) mediates cellular processes in cancer and has been proposed as a therapeutic target. Dalotuzumab (MK-0646) is a humanized IgG1 monoclonal antibody that binds to IGF-1R preventing receptor activation. This study was designed to evaluate the safety and tolerability of dalotuzumab, determine the pharmacokinetic (PK) and pharmacodynamic (PD) profiles, and identify a recommended phase II dose. Experimental Design: Patients with tumors expressing IGF-1R protein were allocated to dose-escalating cohorts of three or more patients each and received intravenous dalotuzumab weekly, every 2 or 3 weeks. Plasma was collected for PK analysis. Paired baseline and on-treatment skin and tumor biopsy samples were collected for PD analyses. Results: Eighty patients with chemotherapy-refractory solid tumors were enrolled. One dose-limiting toxicity was noted, but a maximum-tolerated dose was not identified. Grade 1 to 3 hyperglycemia, responsive to metformin, occurred in 15 (19%) patients. At dose levels or more than 5 mg/kg,

dalotuzumab mean terminal half-life was 95 hours or more, mean Cmin was more than 25 mg/mL, clearance was constant, and serum exposures were approximately dose proportional. Decreases in tumor IGF-1R, downstream receptor signaling, and Ki67 expression were observed. 18F-Fluorodeoxy-glucose positron emission tomography metabolic responses occurred in three patients. One patient with Ewing’s sarcoma showed a mixed radiologic response. The recommended phase II doses were 10, 20, and 30 mg/kg for the weekly, every other week, and every third week schedules, respectively. Conclusions: Dalotuzumab was generally well-tolerated, exhibited dose-proportional PK, inhibited IGF-1R pathway signaling and cell proliferation in treated tumors, and showed clinical activity. The low clearance rate and long terminal half-life support more extended dosing intervals. Clin Cancer Res; 17(19); 1–9. 2011 AACR.

Introduction Authors' Affiliations: 1Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona; 2Bellvitge Hospital, Barcelona; 3Hos- pital Clínico, University of Valencia, Valencia, Spain; 4Merck, Whitehouse Signaling by the insulin-like growth factor (IGF) recep- Station, New Jersey; and 5Massachusetts General Hospital Cancer Cen- tor plays a key role in regulating cellular metabolism, ter, Boston, Massachusetts growth, and cell fate in response to changes in nutrient Note: Supplementary data for this article are available at Clinical Cancer availability (1–3). The IGF receptor 1 (IGF-1R) is a Research Online (http://clincancerres.aacrjournals.org/). tetrameric receptor tyrosine kinase that is widely Portions of this work were presented at the 2008 Annual Meeting of the expressed by normal and neoplastic cells. There are American Society of Clinical Oncology (Chicago, IL). several lines of evidence that suggest that this receptor Corresponding Author: Jose Baselga, Division of Hematology/Oncology, Massachusetts General Hospital Cancer Center, 55 Fruit Street, Lawrence may play a role in the survival and proliferation of human House 108, Boston, MA 02114. Phone: 617-643-2438; Fax: 617-643- tumors. Epidemiologic studies indicate an association 2683; E-mail: [email protected] between plasma IGF-1 ligand levels and increased risk doi: 10.1158/1078-0432.CCR-10-3336 for breast, prostate, and colon cancers (1, 4–6). In 2011 American Association for Cancer Research. colorectal cancer, IGF-1R overexpression correlates with

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Translational Relevance Methods

The results from this clinical study of single-agent Study design dalotuzumab show that the humanized monoclonal This was a multicenter, open-label, single-arm, nonran- antibody is well tolerated in patients with advanced domized phase I clinical trial. Its primary objectives were to cancer. Extensive pharmacodynamic and pharmacoki- establish the PK profile of intravenous dalotuzumab and to netic analyses identified a minimal biologically effec- define the maximum tolerated dose (MTD) of dalotuzu- tive dose, even though a maximum-tolerated dose was mab, should this be encountered before the maximum not determined. The favorable safety and toxicity planned dose was reached (20 mg/kg/wk). Beginning with profile of dalotuzumab, combined with its demon- a weekly dose of 1.25 mg/kg, cohorts of 3 to 6 patients each strated inhibition of IGF-1R signaling and high were treated sequentially with escalating doses of 2.5, 5.0, rate of disease stabilization, make it a good candidate 10, 15, and 20 mg/kg dalotuzumab (Supplementary for combination therapy with chemotherapy and Table S1). The first 4 weeks of dosing were used as the other signal transduction inhibitors. One particular toxicity evaluation period for the purposes of dose escala- þ combination supported by preclinical evidence, dalo- tion. A conventional "3 3" dose escalation scheme was tuzumab in combination with an mTOR inhibitor, used with no intrapatient dose escalation. Once the max- may be beneficial because it prevents the paradoxical imum planned weekly dose (20 mg/kg) was achieved, every activation of the IGF-1R signaling pathway by mTOR other week (Q2W) and every third week (Q3W) schedules inhibitors. were explored with dalotuzumab doses of 20 and 30 mg/ kg, respectively. Patients were to continue on treatment with dalotuzumab until they experienced progressive disease or unacceptable toxicity, withdrew consent, or were tumor cell proliferation, tumor stage, and decreased over- withdrawn at the investigator’s discretion. all survival (7, 8). In preclinical models, IGF-1R activa- Adverse responses to treatment were graded according tion is required to establish and maintain transformed to the National Cancer Institute Common Terminology phenotypes induced by several known oncogenes and Criteria for Adverse Events (NCI-CTCAE version 3.0). confers protection from a number of anticancer therapies Dose-limiting toxicity (DLT) was defined as toxicity of by promoting cell survival through antiapoptotic grade 3 or 4. A maximum of one DLT was counted per mechanisms (1, 9–11). In addition, in experimental patient. Any patient who required more than 2 dose reduc- models, there is ample evidence that inhibition of tions because of DLT was discontinued from the study. If IGF-1R activation results in antitumor activity (1). Taking none of the first 3 patients experienced a DLT at a given these considerations together, IGF-1R was proposed as a dose level, then testing proceeded to the next dose level. If target for cancer therapy and several compounds targeting one of the first 3 patients experienced a DLT, then 3 IGF-1R are in various stages of clinical development additional patients were entered to expand the cohort to (11–21). 6. If 2 patients in a cohort (of 3 or 6) experienced a DLT, Dalotuzumab (MK-0646) is a humanized IgG1 mono- then the MTD was determined as the preceding dose level. clonal antibody (mAb) against IGF-1R selected on the basis Patients with a DLT were withdrawn from the study (except of specificity for IGF-1R over the insulin receptor, and in for infusion reactions and hypersensitivity reactions) un- vitro/in vivo antiproliferative activity against cells that over- less they had resolution of their DLT to baseline or grade 1 express IGF-1R (22). Dalotuzumab binds to IGF-1R with a within 2 weeks of their next scheduled dose (at which time, Kd of approximately 1 nmol/L, induces receptor internal- at the discretion of the investigator, they could continue ization and degradation, and inhibits IGF-1- and IGF-2– receiving treatment at the next lower dose level for the mediated cell proliferation, IGF-1R autophosphorylation, remainder of the study). The safety analysis included all and AKT phosphorylation (23, 24). adverse events reported while patients were receiving treat- This phase I study was aimed to determine the safety, ments and within 30 days following final administrations tolerability, and pharmacokinetic (PK) parameters of study drug. of dalotuzumab when administered to patients with Additional study objectives included evaluation of the advanced solid tumors. On the basis of preclinical data PD effects of dalotuzumab on the IGF-1R–dependent sig- obtained in xenograft models, a trough concentration of naling pathways in skin and tumor and assessment of 25 mg/mL was targeted in this study. Key secondary antitumor efficacy. objectives included determination of the dose at which receptor binding by dalotuzumab is saturated in tumor Patients tissue and exploration of the pharmacodynamic (PD) Main inclusion criteria were presence of a histologically effects of dalotuzumab on IGF-1R–dependent pathways or cytologically confirmed metastatic or locally advanced through sequential tumor and skin biopsies. These objec- tumor that expressed IGF-1R protein and was unresponsive tives were pursued to support characterization of the to standard therapy, patient 18 years or older, life expec- recommended phase II dose for further development. tancy 12 weeks or more, presence of disease accessible to Antitumor efficacy was also assessed. repeated biopsy, Eastern Cooperative Oncology Group

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(ECOG) performance status of 2 or better, and adequate Pharmacodynamics bone marrow, hepatic, and renal functions. Patients were The PD effects of dalotuzumab in tumor and skin were required to have a tumor specimen available for analysis assessed in all patients from whom paired pretherapy and (fresh or recently paraffin-embedded). Expression of on-therapy specimens were available. Processing of the IGF-1R protein was evaluated by immunohistochemistry samples, immunohistochemistry, and statistical analysis and considered positive if staining (of membrane and/or were conducted as described previously (25, 26) and in cytoplasm) was present above background in 10% or the Supplementary Information. Briefly, immunohisto- more of tumor cells in a tissue section. Additional inclu- chemical analysis of total IGF-1R, total and phosphorylated sion criteria are in the Supplemental Information. (p) EGFR (pEGFR), total IRS-1, pAKT (Ser473), pAKT Patients with plasma fasting glucose levels of more than (Thr308), pMAPK (T202/Y204), pS6 (Ser240/4), p4EBP1 150 mg/dL or glycated hemoglobin (HbA1c)of8%or (Thr70), total eIF4E, peIF4G (Ser1108), and Ki67 were more were excluded. All patients gave informed consent, done in formalin-fixed, paraffin-embedded sections from and approval was obtained from the ethics committees tumor and skin samples according to standard methods at each participating institution. The study was conducted (see Supplementary Table S2 for antibody sourcing). Qual- in accordance with Good Clinical Practice guidelines itative changes in the expression of markers were assessed and the Declaration of Helsinki and registered with in a blinded fashion. For quantitative analysis, histochem- ClinicalTrials.gov (NCT00701103). ical scores (H-scores) were calculated by light microscopic examination of complete tumor sections and epidermal Assessments tissue in skin samples, as previously described (25, 26). Vital signs, body weight, ECOG performance status, com- Paired pretherapy and on-therapy samples were analyzed plete blood cell count, and adverse events were assessed using the Wilcoxon rank test by SPSS Data Analysis immediately prior to each dalotuzumab dose. A 12-lead Program version 10.0 (SPSS Inc.). Statistical tests were ECG was recorded when the first dose was given, in the 4th conducted at the 2-sided 0.05 level of significance. Serum or 5th week of treatment, the 9th or 10th week, and once levels of IGF-1 and IGF-2 and IGF-binding protein every 8 to 9 weeks thereafter for the remainder of the trial. (IGFBP)-1, -2, and -3 were measured by ELISA before Serum was collected prior to every dalotuzumab infusion and after 4 weeks on treatment. for PK analysis; PD endpoints in serum were analyzed after 4 to 5 weeks of treatment and at later time points. Skin and Results tumor specimens were obtained at baseline (within 5 days prior to initiation of dalotuzumab) and within 72 hours Patients predose in either the third or fourth week of treatment. Between January 2006 and June 2008, a total of 80 Response of solid tumors to treatment was evaluated patients were enrolled. All data were analyzed and all radiologically (computed tomographic scan or MRI) using patients receiving at least 1 dose of dalotuzumab were Response Evaluation Criteria in Solid Tumors (RECIST) 1.0. included in the safety, PK, and PD analyses. Patients receiv- These evaluations were carried out predose, 9 to 10 weeks ing at least 2 dalotuzumab doses were evaluated for efficacy. after initiating treatments with dalotuzumab, and every 6 to Baseline characteristics for enrolled patients are pre- 8 weeks thereafter for the remainder of the trial. Tumor sented in Table 1. Median patient age was 57 years (range: metabolic rate was assessed by 18F-fluorodeoxy-glucose 19–81), the median number of prior therapies was 3, and positron emission tomography (18FDG-PET) scan within the most frequent malignancies were colorectal (24%) and 120 hours prior to initial dose of dalotuzumab, within 72 breast cancer (21%). The median length of dalotuzumab hours predose in the 3rd or 4th week, the 9th or 10th week, treatment was 44 days (range: 1–324). Five patients dis- and every 16 to 18 weeks thereafter. continued treatment because of treatment-related adverse events, 2 withdrew consent, and 1 discontinued for an Pharmacokinetics unspecified medical reason following the recommendation Blood samples were obtained for measurement of serum of the investigator. Seventy-one patients were removed dalotuzumab levels at the following times: immediately from the study because of disease progression. All patients prior to infusion of the first dose, immediately before the received at least 1 infusion of dalotuzumab and were end of this first infusion, and 0.5, 5, 10, 24, 30, 48, and 96 considered evaluable for safety. hours following the start of this first infusion, and imme- Patients assigned to the weekly regimens of dalotuzumab diately prior to each subsequent infusion. Serum concen- received an average of 7.4 infusions (range: 1–37). Patients trations of dalotuzumab were analyzed by an ELISA that assigned to the 20 mg/kg Q2W regimen received an average used the extracellular domain of recombinant human IGF- of 3.4 infusions (range: 1–5). Patients assigned to the 30 1R to capture dalotuzumab. Captured dalotuzumab was mg/kg Q3W regimen received an average of 5.1 infusions detected by mouse anti-human IgGFC antibodies conjugat- (range: 2–16). ed to horseradish peroxidase. The lower limit of dalotuzumab quantitation in serum was 20 ng/mL. Additional Tolerability ELISA methodology is provided in the Supplementary Of 80 patients enrolled, 67 (83.8%) experienced clinical Information. adverse events, the majority of which were mild to

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Table 1. Patient and disease characteristics Table 2. Summary of treatment-related clinical adverse eventsa Characteristic N ¼ 80 Adverse event Total patients (N ¼ 80) Age, median (range), y 57 (19–81) Gender, n (%) Grade 1–2 Grade 3 All grades Male 40 (50.0) b,c Female 40 (50.0) Hyperglycemia 14 1 15 ECOG performance status, n (%) Asthenia 6 0 6 0 33 (41.3) Chills 2 0 2 1 45 (56.2) Leukocytoclastic 01 1 2 2 (2.5) vasculitis Prior therapies, n (%) Tumor pain 0 1 1 0–1 8 (10.0) Bone pain 1 0 1 2 11 (13.8) Pelvic pain 1 0 1 3 61 (76.3) Nausea 1 0 1 Tumor types, n (%) Infected neoplasm 1 0 1 Colorectal 19 (23.8) Infusion-related reaction 1 0 1 Breast 17 (21.3) Mucosal inflammation 1 0 1 Ewing's sarcoma 6 (7.5) Rash 1 0 1 Ovarian 5 (6.3) Palmar-plantar 10 1 Malignant melanoma 5 (6.3) erythrodysesthesia Bone sarcoma 3 (3.8) Pyrexia 1 0 1 Others 25 (31.3) Myopathy 1 0 1 Decreased appetite 1 0 1

moderate in severity (grades 1–2). Five patients (6.3%) NOTE: Each patient was counted only once within a cate- experienced clinical adverse events of grade 3 or more. gory. When an adverse event was reported more than once The most common clinical adverse events were asthenia, in the same patient with different intensity grades, only the hyperglycemia, back pain, and aspartate aminotransfer- highest grade was counted. a ase elevation, experienced by 21.3%, 18.8%, 13.8%, and Adverse events considered by investigators to be possibly, 10.0% of patients, respectively. Twenty-two patients probably, or definitely treatment related. b (27.5%) experienced a clinical adverse event considered Includes 14 patients with clinical adverse events of hyper- by the investigators to be possibly, probably, or definitely glycemia (including one adverse event of grade 3 intensity) related to dalotuzumab therapy (Table 2). Five patients and one with a laboratory adverse event of increased blood experienced serious adverse events, one of which was glucose level. c considered to be possibly related to the treatment. This In 4 additional patients, adverse events of hyperglycemia n ¼ single drug-related serious adverse event was experienced ( 3, one each with grades 1, 2, and 3) or blood glucose n ¼ by a patient in dose cohort 3 (5 mg/kg) who had grade 3 increased ( 1, grade 1) were reported as not treatment purpura on the lower extremities (diagnosed as leukocy- related because of preexisting or concomitant conditions toclastic vasculitis as per skin biopsy) and resolved in 21 (including acute pancreatitis and corticosteroid treatment). days. Because the drug-related serious adverse event was experienced during the initial 4-week evaluation period, it was considered a DLT and dose cohort 3 was expanded had comparable values in the 5, 10, and 15 mg/kg weekly to 6 patients. No other DLTs were observed. Treatment cohorts (Fig. 1B). The area under the concentration–time was completed at all 8 of the prespecified dose levels curves from time of the first dose (AUC0–¥), estimated from without an MTD being reached. No patients experienced the first dose, increased proportionally with increasing adverse events that required a dose reduction of dalotu- doses (Fig. 1C). zumab. Mean trough concentrations exceeded 25 mg/mL for all weekly doses of 10 mg/kg or more, for 20 mg/kg Q2W, and Pharmacokinetics for 30 mg/kg Q3W (Fig. 1A). Each individual patient in the After the first intravenous dose, mean dalotuzumab weekly 10 mg/kg cohort (n ¼ 6) met this targeted trough plasma concentrations declined biexponentially from peak concentration at the end of the first week of treatment and concentration (Cmax) through 168 hours (Fig. 1A). The continued to meet it in subsequent weeks. There was mean terminal half-life (t1/2) generally increased as doses moderately high interpatient PK variability (coefficients were increased. It was 95 hours or more at all weekly doses of variation generally 25%–50%) in the observed values of more than 5 mg/kg (Table 3). The mean serum clearance for AUC, trough serum concentration, and terminal half- was 0.007 mL/min/kg in the 20 mg/kg weekly cohort and life (Table 3).

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Figure 1. PK behavior of dalotuzumab following administration of weekly intravenous infusions. A, mean serum concentration–time profiles. B, mean serum clearance following first infusion versus dose (error bars, 95% CI). C, exposure

(AUC0–¥) versus dose (error bars, 95% CI). For first dose: n ¼ 5, 1.25 mg/kg; n ¼ 3, 2.5 mg/kg; n ¼ 8, 5.0 mg/kg; n ¼ 6, 10 mg/kg; n ¼ 6, 15 mg/kg; n ¼ 7, 20 mg/kg; n ¼ 11, 20 mg/kg Q2W; n ¼ 11, 30 mg/kg Q3W.

Pharmacodynamics (3, 3, 6, 13, 12, and 15 from the 1.25, 2.5, 5, 10, 15, and 20 We obtained 33 matched pairs of baseline and on- mg/kg dose level cohorts, respectively), and 7 and 10 pairs treatment tumor specimens (2, 5, 6, 7, and 7 pairs from from the 20 mg/kg Q2W and 30 mg/kg Q3W cohorts, the 1.25, 5, 10, 15, and 20 mg/kg weekly dose level cohorts, respectively). It was found that 3 weeks of dalotuzumab respectively, and 3 pairs each from the 20 mg/kg Q2W and treatment significantly reduced mean H-scores (averaged 30 mg/kg Q3W cohorts). We also obtained a total of 69 across all doses) for IGF-1R in both tumor (Fig. 2A; matched pairs of baseline and on-treatment skin biopsies P ¼ 0.02) and skin (Fig. 2B; P ¼ 0.04). This was

Table 3. Dalotuzumab PK parameter values following administration of first intravenous infusion

a Dose, Schedule Doses n AUC0–¥, Ceoi, mg/mL Ctrough, Clearance, Vss, L/kg Apparent b mg/kg before mg/mL h mg/mL mL/min/kg t1/2, h testing

1.25 Weekly 1 5 1.6 (0.4)c 19.4 (1.6) 2.4 (2.2) 0.013 (0.004) 0.072 (0.020) 67 (46–121)d 2.5 Weekly 1 3 3.7 (1.1) 25.1 (10.1) 7.2 (3.0) 0.012 (0.003) 0.088 (0.020) 79 (53–113) 5 Weekly 1 8 12.9 (4.4) 89.1 (16.5) 21.2 (8.3) 0.007 (0.003) 0.061 (0.020) 83 (41–240) 10 Weekly 1 6 28.9 (10.4) 139.4 (22.5) 54.8 (13.3) 0.006 (0.002) 0.091 (0.012) 169 (134–265) 15 Weekly 1 6 39.4 (14.5) 281.0 (54.3) 81.2 (38.6) 0.007 (0.004) 0.068 (0.014) 95 (43–165) 20 Weekly 1 7 52.7 (19.2) 345.4 (61.4) 110.5 (46.0) 0.007 (0.003) 0.082 (0.026) 129 (74–240) 20 Q2W 1 11 45.9 (14.4) 278.5 (115.7) 57.0 (22.7) 0.008 (0.003) 0.079 (0.014) 106 (44–134) 30 Q3W 1 11 92.6 (29.8) 500.0 (138.2) 70.4 (34.1) 0.006 (0.003) 0.080 (0.019) 142 (73–187)

Abbreviations: Ceoi, concentration at the end of infusion; Vss, volume of distribution at steady state. aConcentration at the end of first dosing interval (168 hours for Q1W, 336 hours for Q2W, and 504 hours for Q3W). bHarmonic mean (range). cExcept as indicated otherwise, values are reported as mean (SD). dN ¼ 4 where indicated for 1.25 mg/kg cohort.

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Figure 2. PD effects after dalotuzumab treatment in all the patients included in the study with (A) assessable paired tumor (n ¼ 33) and (B) skin samples (n ¼ 69). Box-plots showing the expression at baseline and on-treatment for the different markers measured by immunohistochemistry. Boxes indicate 90% of the values. Bold lines indicate the mean of the values. External lines indicate the complete range when beyond 90% of the values. Day Pre, baseline sample; Day On, sample obtained at third week prior to cycle 3 of dalotuzumab.

accompanied by significant reductions in the H-scores for noma, adenocarcinoma of unknown origin, metastatic several proteins for which expression levels are known to be bladder cancer, and melanoma) had stable disease per se, modulated by IGF-1R pathway signaling. These included 1 (with Ewing’s sarcoma) had a mixed response (Supple- pS6 (P ¼ 0.031), pEIF4G (P ¼ 0.046), pMAPK (P ¼ 0.035), mentary Fig. S2), and 1 (with a neuroendocrine tumor) had and Ki67 (Fig. 2A; P ¼ 0.03). The mean H-score for a minor response. These responses ranged in duration from epidermal growth factor receptor (EGFR) was also signif- 13 to 43 weeks (Supplementary Table S3). In addition, icantly decreased (P ¼ 0.016). In Figure 3A and B, repre- 18FDG-PET metabolic responses were observed in 3 sentative images are shown for changes in biomarker patients. One patient in the 15 mg/kg dose level cohort, expression observed in tumor and skin specimens obtained diagnosed with melanoma, achieved disease stabilization prior to treatment and on day 14. These are from a patient for 13 weeks and a decrease in 18FDG uptake from 38 to 25 treated weekly with 15 mg/kg dalotuzumab. g/mL (ratio ¼ 0.66, assessed after 8 weeks of dalotuzumab These decreases in tumor and skin expression of IGF-1R treatment; Supplementary Fig. S3a). The observed decrease were accompanied by altered serum levels of markers of in 18FDG uptake correlated with decreased tumor Ki67 IGF-1R pathway activation (Supplementary Fig. S1). Pool- expression as assessed by immunohistochemical staining ing outcomes across all dose cohorts, mean serum IGF-1 and (Supplementary Fig. S3b). IGF-BP3 levels were increased by 153% and 41%, respectively, after 5 weeks of therapy. No other markers showed Discussion any consistent pattern of change (Supplementary Fig. S1). In this first in-human study of dalotuzumab, this Efficacy humanized anti-IGF-1R mAb was generally well tolerated Of 80 patients enrolled, 76 had tumors evaluable for throughout the range of doses tested, including 1.25 to 20 efficacy by RECIST. Per these criteria, stable disease was mg/kg administered weekly, 20 mg/kg Q2W, and 30 mg/kg observed in 6 of these patients. Four (with cholangiocarci- Q3W. The most common adverse event was hyperglycemia,

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Figure 3. Biomarker expression changes in (A) tumor [IGF-1R, EGFR, pS6 (Ser240/4), pMAPK (T202/Y204), peIF4G (Ser1108), and Ki67] and (B) skin [IGF-1R, pMAPK (T202/Y204), and eIF4E] samples between baseline (day 0) and on-treatment (day 14) in a selected patient treated at 15 mg/kg weekly.

which was considered to be treatment related in 15 (19%) variability in AUC, trough serum concentration, and of the 80 patients treated with dalotuzumab. In addition, terminal half-life observed in this study was comparable there were 4 cases of hyperglycemia that investigators with that observed previously with other IGF-1R mAbs (16, considered to be not treatment related. Hyperglycemia is 17). The physiologic basis for this PK variability is unclear, recognized as a potential adverse effect of treatment with although contributing factors may include individual dif- anti-IGF-1R antibodies (27). In prior studies of AMG-479 ferences in tumor burden, tumor type, and tumor expres- and figitumumab, it was reported in 7 of 53 (13%) and 5 of sion levels of IGF-1R. 29 (17%) treated patients, respectively (16, 17). When it On the basis of PD data from preclinical models, 25 mg/ occurred in the present study, it was adequately controlled mL was prespecified as the targeted minimum serum by oral antihyperglycemic agents and did not interfere with trough concentration in this study. This target was dalotuzumab dosing. Thrombocytopenia has also been achieved in all patients who received 10 mg/kg of dalo- reported (as a DLT) in a prior study of dalotuzumab tuzumab weekly, 20 mg/kg Q2W, or 30 mg/kg Q3W, and (28) and also in a study of the anti-IGF-1R antibody it seems (as discussed earlier) that such doses achieved AMG-479 (16). None was observed in the present study. target saturation. Consequently, all of these doses and The maximum planned dose (20 mg/kg) was reached in schedules are recommended phase II doses for use in this dose-escalation study and thus the MTD was not future evaluations of dalotuzumab. We have chosen a determined. dose of 10 mg/kg weekly for a number of follow-up As with other mAbs targeted at cell-surface receptors, studies in breast cancer. binding of dalotuzumab to its target (IGF-1R) triggers Dalotuzumab treatment induced a series of mechanisti- receptor-mediated endocytosis (23). The PK behavior of cally based PD effects. Most notably, we observed signif- dalotuzumab is thus expected to conform to a pattern of icant reductions in IGF-1R protein expression in tumor target-mediated disposition such that low doses insuffi- and skin, consistent with the known induction of IGF-1R cient to saturate the target will produce clearance kinetics internalization and degradation that follows dalotuzumab dominated by high-affinity binding of dalotuzumab to its binding to IGF-1R (23, 24). Decreased IGF-1R signaling target (followed by its irreversible internalization into was also achieved, as indicated by significant on-therapy target cells) and high doses will produce kinetics associated decreases in tumor pS6, pEIF4G, and Ki67 expression. with FcRn-mediated protection of dalotuzumab from Significant increases in serum IGF-1 and IGF-BP3 levels intracellular degradation (followed by its release into the were observed, and such increases are expected as a plasma and/or interstitial space; ref. 29). When examined compensatory reaction to disruption of IGF-1R function. over a range of doses, generally linear PK behavior is not Among the 80 patients enrolled in the present study, 72 expected until saturation of the target has been achieved. (90%) received doses of dalotuzumab likely to have satu- Using this model as the basis for interpreting the present PK rated IGF-1R. Hence, this study did not have a design suited findings, it seems that target saturation was achieved by for the observation and characterization of dose depen- weekly doses of 5.0 mg/kg or more. The interpatient dency in either PD or antitumor effects.

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The efficacy data currently available from clinical studies transduction pathway, dalotuzumab is currently being eval- of IGF-1R–targeted mAbs are limited, and phase I clinical uated in combination with chemotherapy and with other trials such as the present study are not primarily designed to signal transduction inhibitors. For example, mTOR inhibi- test efficacy. Thus, the available data must be interpreted tion results in activation of upstream AKT that could result in with caution. The data do seem to show, however, that decreased therapeutic efficacy (26). mTOR inhibitor– some advanced, solid tumors respond to monotherapy mediated activation of AKT is due to a paradoxical activation with these agents, although most do not. In the present of the IGF-1R signaling pathway (25, 32). Coadministration study, there was RECIST-defined disease stabilization of dalotuzumab prevents mTOR inhibitor–mediated acti- (including 1 partial and 1 mixed response) in 6 of the vation of AKT, providing a strong rationale for clinical 76 patients (7.9%) who received dalotuzumab monother- investigation of dalotuzumab and mTOR inhibitor combi- apy and had tumors evaluable by RECIST. In a phase I trial nations. An ongoing phase I clinical study is exploring this of the agent AMG-479, there was antitumor activity in 4 of approach with a combination of dalotuzumab with the 53 patients treated (7.5%), with one of these being a mTOR inhibitor ridaforolimus (NCT00730379) and recent- complete response that was maintained for at least ly reported encouraging clinical activity, especially in 28 months (16). In a trial of the anti-IGF-1R antibody patients with estrogen receptor–positive, highly prolifer- IMC-A12 in patients with metastatic colorectal cancer that ative tumors (33). Preclinical models suggest a synergistic was refractory to cetuximab or panitumumab, no antitu- effect on tumor growth inhibition when dalotuzumab is mor activity was observed among the 23 patients who combined with cetuximab, an anti-EGFR mAb (22). The received IMC-A12 monotherapy and a single partial re- activity of dalotuzumab combined with irinotecan/cetuxi- sponse was observed among the 41 patients who received mab is being evaluated in patients with refractory, metastatic IMC-A12 plus cetuximab (20). On the other hand, in a colorectal cancer with wild-type KRAS (NCT00925015). prior study of the IGF-1R–targeted antibody figitumumab In summary, dalotuzumab is generally well tolerated and, in which inclusion was restricted to patients with sarcomas, at the recommended dose and schedule, achieves desired there was disease stabilization or an objective response in serum exposures and decreases tumor IGF-1R protein levels, 10 of 28 patients assessed (17). downstream IGF-1R signaling, and Ki67 expression. The higher rate of responses in patients with sarcomas suggests that other specific populations or factors may Disclosure of Potential Conflicts of Interest be identified that predict who will benefit from IGF-1R– targeted monotherapy or combinations of IGF-1R–targeted H. Brown, J. Clark, J.S. Hardwick, R.A. Beckman, W.D. Hanley, K. Hsu, and R.B. Langdon are current employees of Merck & Co., Inc., or were at the mAbs with other agents. In this regard, a recent trial with time the study was conducted. J. Tabernero, J. Baselga, and E. Calvo have figitumumab has reported significant correlation between served as compensated scientific advisors to Merck & Co., Inc. J. Baselga is a consultant/advisory board member of Merck & Co., Inc. F. Atzori, A. pretreatment levels of free IGF-1 and objective responses to Cervantes, L. Prudkin, J. Andreu, E. Rodriguez-Braun, A. Domingo, J. anti-IGF-1R therapy in patients with advanced non–small- Guijarro, C. Gamez, J. Rodon, S. Di Cosimo, and S. Rosello have no cell lung cancer treated with figitumumab plus paclitaxel or conflicts of interest to disclose. The corresponding author had final respon- sibility for the decision to submit the manuscript for publication. carboplatin (21). In the present trial, most tumors did not respond to treatment despite selection for patients with Authors' Contributions tumors that expressed IGF-1R. Because all patients in the present study had IGF-1R–expressing tumors, it remains J. Tabernero, H. Brown, J. Clark, K. Hsu, R.A. Beckman, and J. Baselga unknown whether or not the presence of such expression contributed to the conception and design of the study. F. Atzori, J. Taber- nero, A. Cervantes, J. Andreu, E. Rodriguez-Braun, A. Domingo, J. Guijarro, was a necessary condition for clinical benefit. It is possible J. Rodon, S. Di Cosimo, S. Rosello, and J. Baselga contributed to data that tumor IGF-1R expression has little or no predictive collection. F. Atzori, J. Tabernero, A. Cervantes, L. Prudkin, C. Gamez, S. Di Cosimo, H. Brown, J. Clark, J. Hardwick, R.A. Beckman, W.D. Hanley, K. value about response to dalotuzumab treatment, just as Hsu, E. Calvo, R.B. Langdon, and J. Baselga conducted data analyses or tumor expression of the EGFR in metastatic colorectal interpreted the results. All authors reviewed manuscript drafts, contributed cancer is not correlated with tumor response to mAbs to manuscript revisions, and approved the final, submitted version. targeting the EGFR (30). When tumor target expression is found to lack predictive value, there may be underlying Acknowledgments technical reasons, such as sampling bias, variability in The authors thank Meritxell Soler, Gemma Sala, Javier Cortes, Rafael sample handling, limited assay sensitivity or specificity, Simo, Kuo Yin, and Ryan Geschwindt for their assistance in data collection or evolution of tumors between when biopsies were and patient management. The authors also thank all of the patients, nurses, obtained and treatments applied (31). Given, however, and site staff who participated in the study. the presence of multiple redundant signaling pathways within tumor cells, intervention by monotherapy to per- Grant Support turb a single signaling pathway alone may simply be This study was funded by Merck & Co., Inc., manufacturer of dalotuzumab. inadequate for clinical benefit in the majority of patients. The costs of publication of this article were defrayed in part by the payment This may explain why we observed significant PD activity in of page charges. This article must therefore be hereby marked advertisement in the present study, but with limited efficacy. accordance with 18 U.S.C. Section 1734 solely to indicate this fact. On the basis of the favorable safety profile, efficacy Received December 17, 2010; revised June 29, 2011; accepted July 10, data, and inhibition of IGF-1R and its downstream signal 2011; published OnlineFirst August 2, 2011.

OF8 Clin Cancer Res; 17(19) October 1, 2011 Clinical Cancer Research

Phase I PK/PD Study of Dalotuzumab in Advanced Cancer Patients

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www.aacrjournals.org Clin Cancer Res; 17(19) October 1, 2011 OF9

A Phase I Pharmacokinetic and Pharmacodynamic Study of Dalotuzumab (MK-0646), an Anti-Insulin-like Growth Factor-1 Receptor Monoclonal Antibody, in Patients with Advanced Solid Tumors

Francesco Atzori, Josep Tabernero, Andrés Cervantes, et al.

Clin Cancer Res Published OnlineFirst August 2, 2011.

Updated version Access the most recent version of this article at: doi:10.1158/1078-0432.CCR-10-3336

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