Phase I Study of E7820, an Oral Inhibitor of Integrin A-2 Expression with Antiangiogenic Properties, in Patients with Advanced Malignancies

Clinical Cancer Cancer Therapy: Clinical Research

Phase I Study of E7820, an Oral Inhibitor of Integrin a-2 Expression with Antiangiogenic Properties, in Patients with Advanced Malignancies

Monica Mita1, Kevin R. Kelly1, Alain Mita1, Alejandro D. Ricart1, Ofelia Romero1, Anthony Tolcher1, Laurel Hook2, Chukwuemeka Okereke2, Ilya Krivelevich2, Daniel P. Rossignol2, Francis J. Giles1, Eric K. Rowinsky1, and Chris Takimoto1

Abstract Purpose: This phase I study was conducted to characterize the safety profile, pharmacokinetics, pharmacodynamics, dose-limiting toxicity (DLT), and the maximum-tolerated dose of E7820, a novel oral sulfonamide derivative with antiangiogenic properties, when administered to patients with advanced solid malignancies. Patients and Methods: Patients received single daily doses of E7820 orally for 28 days in cycle 1, followed by a 7-day no-treatment period, after which time-uninterrupted daily dosing ensued. The starting dose of E7820 was 10 mg/d, which was increased to 20, 40, 70, 100, and 200 mg/d in cohorts of new patients. Results: Thirty-seven patients [21 male; median age 65 (40–82] were enrolled. At 100 mg/d, 1 patient experienced a DLT consisting of grade 3 neutropenia, thrombocytopenia, and elevated liver enzymes. At the 200-mg dose level, 2 patients experienced grade 4 thrombocytopenia and neutropenia. No partial or complete responses were observed; 8 patients had stable disease (4 months), including 5 patients with protracted stable disease exceeding 6 months. Mean time to maximum plasma concentration values ranged from 1 to 12 hours, whereas mean terminal half-life values ranged from 5.6 to 8.6 hours. Flow cytometric analysis of platelet integrin a-2 expression showed a sustained greater than 50% decrease beyond day 28 in 3 of 4 patients at 200 mg, whereas moderate (<30%) decreases were observed at 70- and 100-mg dose levels. Conclusions: The recommended phase II dose of E7820 is 100 mg/d, based on a fasting schedule. E7820 downregulates integrin a-2 expression in surrogate tissues (platelets) and is associated with stable disease in a wide variety of heavily pretreated malignancies. Clin Cancer Res; 17(1); 193–200. 2011 AACR.

Introduction Integrins regulate angiogenesis by promoting the proliferation and survival of endothelial cells (5). Embryonic deletion Integrins are transmembrane glycoprotein receptors that of key integrins results in defects in the organization and play key roles in angiogenesis and are essential for endothe- proliferation of early vasculature and the ability of endothelial cell migration, proliferation, and survival (1). They con- lial cells to form blood vessels (6, 7). The therapeutic poten- trol cellular adhesion to extracellular matrix proteins found tial of integrins as a drug target became clear when it was in intercellular spaces and basement membranes and also shown that small peptide and antibody antagonists of integ- transduce signals that promote cell proliferation, migration, rins could inhibit tumor angiogenesis, growth, and metas- and cell survival (2). These effects are mediated by inhibition tasis (8, 9). Several integrin inhibitors have been evaluated in of caspase activation, anchoring of actin filaments to the clinical trials including cilengitide, a cyclic peptide antagonist basement membrane, and stimulation of cyclins (3, 4). of integrins avb3andavb5usedasatreatmentoptionfor glioblastoma, and etaracizumab a humanized monoclonal antibody against avb3 integrin receptor (10, 11). Authors' Affiliations: 1Institute For Drug Development, Cancer Therapy E7820 [N-(3-cyano-4-methyl-1H-indol-7-yl)-3-cyano- and Research Center at the University of Texas Health Science Center, 2 benzene-sulfonamide] is a first-in-class, orally available San Antonio, Texas; and Eisai Incorporated, Woodcliff Lake, New Jersey aromatic sulfonamide derivative that inhibits the prolifera- M. Mita and K.R. Kelly are co-first authors. tion and tube formation of human umbilical vein cells Corresponding Author: Monica Mita, Institute for Drug Development, induced by either basic fibroblast growth factor or VEGF Cancer Therapy and Research Center at University of Texas Health Science Center, San Antonio, TX 78229. Phone: 210-450-1000; Fax: (12). This inhibition seems to be mediated through 210-450-1100; E-mail: [email protected]. suppression of endothelial integrin a-2 mRNA and to a doi: 10.1158/1078-0432.CCR-10-0010 lesser extent integrin a-3, a-5, and b-1 mRNA expression. 2011 American Association for Cancer Research. Preclinical studies have shown that oral administration of

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Translational Relevance a history of prior hypersensitivity to sulfonamide deriva- tives; treatment with chemotherapy or radiation involving Integrins are transmembrane glycoproteins that are at least 25% of hematopoietic reserves within 4 weeks; the important in angiogenesis and cell proliferation, migra- persistence of any clinically significant side effects to prior tion, and survival. The realization that integrin inhibi- chemotherapy or radiotherapy; clinically or radiologically tion impairs tumor growth and metastasis prompted the progressive central nervous system metastasis, active infec- development of integrin inhibitors some of which are tion with hepatitis B or C, or human immunodeficiency now in clinical use. E7820 is an orally available, aro- virus active, uncontrolled, intercurrent infection; major matic sulfonamide derivative that has shown antitumor surgery within 4 weeks; a history of unstable ischemic and antiangiogenic effects in preclinical models of disease, clinically significant thrombosis, documented vas- human colon, breast, and renal cancer. This effect is cular headache with neurologic changes; antithrombotic believed to be mediated through the suppression of therapy or therapeutic anticoagulant therapy; pregnancy or integrin a-2 mRNA. We report the first in human breast-feeding; less than 30% of ideal weight for height and phase I study of E7820 in patients with refractory solid age; or other significant disease that in the investigator tumors. Treatment with E7820 resulted in significant opinion would contraindicate the participation in the decreases in platelet integrin a-2 expression at the study. Patients provided written consent according to the maximum-tolerated dose. Although no objective federal and institutional requirements. responses were observed, E7820 treatment was associated with prolonged stable disease in a substantial Trial design and dose escalation number of heavily pretreated patients. Higher doses Patients received daily dosing of E7820 for 28 days in were associated with toxicities such as grade 3 or 4 cycle 1, followed by a 7-day no- treatment rest period. thrombocytopenia, neutropenia, and bleeding. Thereafter, patients had continuous daily dosing. One cycle was defined as a 28-day treatment period. Patients received fixed doses of E7820 beginning at 10 mg. The 10-mg starting E7820 inhibits tumor growth and reduces angiogenesis in dose was chosen, as it represented one tenth of the exposure subcutaneously implanted human colon, breast, and kid- level (as mg/kg) that showed minimal reversible effects in ney cells in mice (12). Similar effects were seen in ortho- dogs. Additional dose levels explored were 20, 40, 70, 100, topically implanted human pancreatic KP-1 and colon and 200 mg. At least 3 patients were enrolled in each cohort Colo320DM tumors (13). Furthermore, administration according to the following rules: if no patient experienced of E7820 resulted in a decrease in cell-surface expression DLT, the dose escalation continued; if 1 of 3 patients of mouse platelet integrin a-2 at doses associated with experienced DLT, an additional 3 patients were treated at antitumor activity, suggesting platelet integrin a-2 expres- the same dose level; if no additional patient experienced sion may be used as a biomarker of E7820 activity. DLT, the dose escalation was continued; and if at least 2 On the basis of this promising preclinical data, this first- patients in any cohort of up to 6 patients experienced DLT, in-human phase I study was designed to determine the dose escalation was terminated and additional patients were dose-limiting toxicities (DLT) and the maximum-tolerated to be entered at the next lower dose level. MTD was defined dose (MTD) of oral E7820 in patients with malignant solid as the highest dose that does not meet the DLT dose–level tumors. Additional study objectives included defining the definition. The DLT dose level was defined as the lowest safety profile of E7820, estimation of the pharmacokinetic dose level at which DLT was experienced in 2 or more and pharmacodynamic parameters, characterizing the patients of a maximum of 6 patients. effects of food on drug kinetics, and the documentation Intrapatient dose escalation was permitted on a case-by- of any preliminary antitumor activity of E7820. case basis. DLT was defined as grade 3–4 nonhematologic toxicity excluding untreated nausea and vomiting and Patients and Methods untreated diarrhea; grade 3–4 thrombocytopenia and neutropenia and failure to administer 75% or greater of the Patient selection planned dose of E7820 to an individual patient due to Patients with solid malignancies for whom standard drug-related toxicities. Patients were requested to complete treatment failed or for whom adequate therapy was not a daily medication administration log and to report any available were eligible for this study. Relevant eligibility side effects to study site personnel as soon as possible. Side criteria included: an age at least 18 years; a Karnofsky effects were graded according to the National Cancer Insti- performance status (KPS) of at least 70%; a life expectancy tute Common Terminology Criteria for Adverse Events of at least 3 months; and adequate renal (creatinine 1.5 (CTCAE), Version 3. Patients remained on study until they mg/dL or creatinine clearance 60 mL/min/1.73 m2), no longer experienced clinical benefit, had progressive hematopoietic (absolute neutrophil count 1,500/mm3 disease, or experienced unacceptable toxicity. and platelets 100,000/mm3) and hepatic function (bilir- ubin 1.5 mg/dL and aspartate transaminase 2.5 times Pharmacokinetic studies upper limit of normal or 5 times upper limit if due to liver Blood sample collection for pharmacokinetic analysis metastases). Study exclusion criteria included the following: were done on cycle 1 day 1 and 28 at predose and at 0.25,

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0.5, 1, 1.5, 2, 2.5, 3, 4, 5, 6, 8, 12, and 24 hours after drug ing 1 to 2 cycles. All patients received at least 1 dose of administration. A blood sample for plasma protein binding E7820 and all patients were included in the safety popula- study was also collected on cycle 1 day 1. A 24 hours urine tion, pharmacokinetic, and pharmacodynamic data. collection for pharmacokinetic analysis was done on cycle Patient characteristics are summarized in Table 1. A broad 1 day 1 through day 2. Bioanalysis of urine and plasma range of tumor types was represented. Thirty-five patients samples was done using liquid chromatography-tandem received prior chemotherapy, including 3 patients who had mass spectrometry (LC-MS/MS) on a reversed-phase sys- previously received bevacuzimab. Fourteen patients tem using a C18 column and a Perkin Elmer Sciex API 3000 received prior radiotherapy. mass spectrometer for detection (14). The upper limit of Patients were enrolled in cohorts of 3, starting with a quantitation was established at 250 ng/mL and the lower dose of 10 mg/d. The dose was doubled up to 40 mg/d and limit of quantitation was 1 ng/mL. Accuracies were within then increased to 70 mg/d. Four patients were then the 85% to 115% interval and precision was less than 15%. enrolled at 100 mg/d (1 patient was replaced for not The calibration curve was linear over this concentration completing 21 days of therapy due to disease-related range. The concentration of free and bound E7820 was decreased performance status). No DLTs were noted in determined using modified Scatchard equations as pre- these 4 patients. As there were no significant changes in viously described (15). Patients were required to fast over- pharmacokinetic parameters between the 70- and 100-mg night before dosing for pharmacokinetic analysis. Food groups, the next cohort of treated patients were treated at effect was assessed in 7 patients receiving 100 mg of E7820 200 mg. Six patients were then enrolled at 200 mg/d, and 2 and 1 patient receiving 200 mg on day 1 of cycle 2 by fasting patients experienced DLTs at this dose level. overnight and then consuming a standard high-fat break- An additional 13 patients (17 patients in total) were fast 30 minutes before the dose of E7820 and repeating the enrolled at 100 mg. Only 1 patient experienced a DLT at same pharmacokinetic analysis done on day 1 of cycle 1. this dose level and therefore the DLT dose level was established as 200 mg/d and the MTD and the recom- Pharmacodynamic studies mended dose for further testing of E7820 was 100 mg/d Blood samples for integrin a-2 assay were collected at based on a fasting schedule. predose and at 6 hours postdrug dosing on day 1, at 24 hours postdrug dosing on day 2, and at predose dosing on Safety day 28 of cycle 1. Beyond cycle 1, for each subsequent cycle, All treated patients were assessed for safety. The toxicities samples were collected on day 28 only. Platelet integrin a-2 of all grades considered possibly or probably related to expression was measured using flow cytometry as pre- study medication are summarized in Table 2. Toxicities viously described (13). were reported at all dose levels. The most common side effects were nausea, fatigue, diarrhea, and anemia and most Response criteria were Common Terminology Criteria grade 1 or 2. Grade 3 The effect of E7820 on tumor size was assessed by tumor or 4 toxicities were reported only at the 100- and 200-mg measurements and clinical assessments. Clinical assessments dose levels. Most grade 3 or 4 toxicities were hematologic. were done at screening and during every cycle. Tumor assess- Toxicities leading to study discontinuation occurred in 1 ments (computed tomography and/or magnetic resonance patient in the 100-mg dose level and 2 patients in the 200- imaging) were done at baseline and every 2 cycles thereafter, mg dose level, and no patients discontinued the study due while on treatment, and at study termination. To ensure to toxicities at the lower dose levels. consistency, the same imaging technique was used through- In the 100-mg dose level, a 74-year-old male patient with out the study in individual patients. Criteria for evaluating colon cancer and initially normal bone marrow function tumor response were modified from the Response Evalua- developed grade 4 thrombocytopenia and neutropenia, tion Criteria in Solid Tumors (RECIST 1.0) guidelines (16). renal and liver dysfunction (grade 4 hyperbilirubinemia), As E7820 was expected to slow tumor growth rather than and urosepsis 21 days after starting study medication that induce tumor regression, progressive disease was defined in was subsequently fatal. A 62-year-old patient treated in the the protocol asat least a 50% increase in the sum of the largest 200-mg dose level with a history of cervical cancer devel- diameter (LD) of target lesions, taking as reference the oped grade 3 mucositis and pancytopenia (grade 4 throm- smallest summed LD recorded since the treatment started bocytopenia and neutropenia and grade 3 anemia). She or the appearance of 1 or more new lesions. later died with uncontrolled uterine bleeding secondary to advanced cervical cancer and thrombocytopenia. A 75- Results year-old female patient who was also treated at the 200- mg dose level, with a history of metastatic breast cancer, General developed grade 2 thrombocytopenia resulting in interrup- Thirty-seven patients with advanced or refractory malig- tion of study drug at day 14 for the remainder of cycle 1. nancies were enrolled and received 107 cycles of treatment. Her platelet count returned to normal, and she restarted The overall mean duration of exposure to E7820 was 88.6 E7820 at 200 mg for cycle 2 of therapy but stopped at days (range, 1–448). The duration of treatment ranged day 47 when she developed grade 4 thrombocytopenia from 0 to 16 cycles, with the majority of patients complet- (platelet count 23 109/L). The study medication was

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Table 1. Patient characteristics patients (37.8% of total) experienced stable disease lasting 8(n ¼ 2, 5.4%), 16 (n ¼ 4, 10.8%), 20 (n ¼ 1, 3.7%), 24 (n Characteristics No. Range % ¼ 2, 5.4%), 32 (n ¼ 2, 5.4%), 40 (n ¼ 2, 5.4%), and (N ¼ 37) 52 weeks (n ¼ 1, 3.7%) based on the protocol definition of response. On the basis of the protocol definition of Age, y response, patients with a greater than 25% but less than Mean 65 50% increase in the sum of longest diameters (RECIST Range 40–82 definition of progression) were not considered as having Gender (male:female) 21:16 progressive disease. There were no complete or partial Ethnicity responses and 15 patients (40.5%) had progressive disease. Caucasian 32 86.5 Tumor response was not evaluated in 8 patients due to early African–American 1 2.7 cessation of treatment. Hispanic 4 10.8 Karnofsky performance score Pharmacokinetics Median 82% E7820 is rapidly absorbed following oral administration. Range 70%–100% After a single dose, mean peak plasma concentrations <70% 0 0 ranging from 0.19 mg/mL (10-mg dose level) to 1.86 mg/ 70% 5 13.5 mL (200-mg dose level; ref. Table 3 and Fig. 1) were 80% 22 59.5 achieved within 2.17 to 5.33 hours postdosing [mean time 90% 8 21.6 to maximum plasma concentration (tmax)]. The maximum 100% 2 5.4 concentration (Cmax) and area under the curve (AUC) No. of prior chemotherapy values increased with escalating doses, although less than 0 2 5.4 proportional dose increases were observed over the 70- to 1 7 18.9 200-mg dose range (Fig. 1A and B). Mean AUC0–24 values 2 9 24.3 ranged from 1.2 (10-mg dose level) to 21.6 (200-mg dose 30 0level) mg h/mL (Table 3 and Fig. 1B). The mean terminal 410 27half-life of E7820 ranged from 5.6 to 8.6 hours. The 5þ 9 24.3 pharmacokinetic parameters were similar on days 1 and Prior radiotherapy 14 37.8 28 following continuous E7820 administration (Fig. 1A Primary cancer type and B). A small degree of drug accumulation occurred after Colorectal 10 27 28 days of continuous dosing of E7820 as expected from Renal cell 3 8.1 the observed half-life. On days 1 and 28, the mean Cmax Non–small-cell lung 2 5.4 values at 100 mg/d were 1.49 and 2.07 mg/mL, respectively. Head & neck 2 5.4 The day 1 and 28 AUC values were 14.8 and 20.3 mg h/mL, Bladder 2 5.4 respectively. In vivo assessment of protein binding showed Ovary 2 5.4 that E7820 is highly protein bound and all patients had free Pancreas 2 5.4 concentrations of E7820 of less than 1%. As expected, less Prostate 2 5.4 than 1% of the dose was excreted in the urine. A summary Esophageal 2 5.4 of E7820 pharmacokinetics after a single, oral dose of Carcinoid 2 5.4 E7820 is presented in Table 3. The patient treated with Othera 8 21.6 200 mg of E7820 who developed grade 4 thrombocytopenia and uncontrolled vaginal hemorrhage on day 14 of aMelanoma, Ewing sarcoma, breast, cervix, thyroid, penis, treatment had an aberrantly high Cmax after cycle 1 day 1 of anus, and peritoneal. 2.65 mg/mL compared with a mean of 1.86 mg/mL for all the 200-mg dose patients. The derived pharmacokinetic parameters for cycle 1 discontinued and her platelet count returned to normal day 1 (fasting) and cycle 2 day 1 (fed) subjects were 3 weeks later. This was considered a DLT because the compared. The geometric mean AUC0–t increased by subject received less than 75% of the planned dose of approximately 58% and the geometric mean Cmax E7820 due to thrombocytopenia during cycle 1. increased by approximately 43% during the fed period Six patients died during the study or within 30 days after for subjects in the 100-mg dose group. A full study inves- the last treatment, 4 due to progressive disease, 1 due to tigating the safety and pharmacokinetics of E7820 under sepsis, and 1 due to vaginal hemorrhage as described earlier. fed conditions is planned.

Tumor response Pharmacodynamics Among the 37 treated patients, 29 were evaluated for Cell-surface expression of integrin a-2 on circulating response. There were no objective responses. Among the 37 platelets at predose baseline was compared with that found treated patients, 29 were evaluated for response. Fourteen predose on cycle 1 day 28. As shown in Figure 2, expression

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Table 2. Toxicities considered E7820 related

E7820 daily dose at start date of toxicity (no. of patients treated) clincancerres.aacrjournals.org

10 mg (3) 20 mg (4) 40 mg (3) 70 mg (4) 100 mg (17) 200 mg (6) Overall (37)

Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade 1/2 3/4 1/2 3/4 1/2 3/4 1/2 3/4 1/2 3/4 1/2 3/4 1/2 3/4

Hematologic toxicity Anemia 1 (25) 4 (23) 1 (17) 1 (17) 6 (16) 1 (3) Neutropenia 1 (6) 2 (33) 3 (8) Thrombocytopenia 1 (6) 2 (33) 3 (8) Nonhematologic toxicity Abdominal pain 1 (33) 1 (6) 2 (5) on September 28, 2021. © 2011American Association for Cancer Constipation 2 (67) 1 (25) 1 (17) 4 (11) Research. Diarrhea 2 (67) 3 (75) 1 (25) 4 (23) 3 (50) 13 (35) Dry mouth 1 (6) 1 (3) Nausea 2 (67) 2 (50) 3 (100) 2 (50) 6 (35) 1 (17) 16 (43) Stomatitis 1 (33) 1 (25) 1 (6) 1 (6) 1 (17) 3 (8) 2 (5) Vomiting 1 (33) 1 (33) 4 (23) 6 (16) Chest pain 1 (6) 1 (3) Fatigue 2 (66.6) 1 (25) 1 (33) 1 (25) 7 (41) 2 (33) 14 (38) Peripheral edema 2 (12) 2 (5) Pyrexia 1 (33) 1 (17) 2 (5) Palpitations 2 (12) 2 (5)

lnCne e;1()Jnay1 2011 1, January 17(1) Res; Cancer Clin Elevated alanine aminotransferase 1 (25) 1 (6) 1 (17) 3 (8) Elevated aspartate aminotransferase 1 (25) 2 (12) 1 (17) 4 (11) Elevated alkaline phosphatase 1 (33) 1 (25) 1 (6) 1 (17) 4 (11) Hyperbilirubinemia 1 (6) 1 (17) 1 (3) 1 (3) Vaginal hemorrhage 1 (17) 1 (3)

Hemoptysis 1 (6) 1 (3) E7820 of Study I Phase

NOTE: All toxicities that were felt to be possibly, probably, or definitely related to E7820. The values given are number of patients (% of patients) with toxicity. 197 Mita et al.

Table 3. Relevant E7820 pharmacokinetic parameters (mean values SD)

a Dose, mg/d No. of Cmax, mg/mL tmax, h AUC0–24, t1/2 Vss/f, L Cl/f, L/h patients mg h/mL

10 3 0.19 0.04 2.17 1.04 1.2 0.5 5.6 3.41 84.6 43.5 10.8 1.2 20 4 0.45 0.12 2.38 0.63 2.8 1.3 6.37 1.34 67.0 21.1 7.8 3.9 40 3 0.74 0.51 5.33 5.77 5.3 2.6 7.054 1.17 54.5 7.4 5.4 0.2 70 4 1.77 0.58 2.63 1.25 17.7 7.1 6.30 0.15 29.3 12.6 3.2 1.3 100 17 1.49 0.68 3.21 3.12 14.8 7.7 6.58 1.71 76.7 46.5 8.4 5.2 200 6 1.86 0.74 3.42 3.34 21.6 10.5 8.60b 75.2b 6.1b

Abbreviations: AUC0–24, area under the curve; t1/2, half-life; Vss, volume of distribution; Cl, clearance. a Mean tmax for each group. bNo standard deviations are available for the last 3 parameters.

of integrin a-2 was decreased as a function of increasing E7820 dosing. Decreases in platelet integrin a-2 expression A 6 were not observed in the 10 and 20 mg/d cohorts, however, patients treated at 100 mg showed a decrease of approxi- 5 mately 25% by day 28. Consistent with known kinetics of platelet turnover, decreased integrin a-2 expression was not 4 observed on cycle 1 day 8 (8 days after beginning dosing; data not shown), whereas reductions in integrin a-2 expres- 3 sion seen at the end of cycle 1 were retained in the 100- and ( µ g/mL) 200-mg cohorts 8 days after cycle 1 dosing was stopped max

C 2 (samples obtained cycle 2 day 1; data not shown).

1 Discussion

0 This trial shows that E7820 can be safely administered to 0 50 100 150 200 250 patients with advanced cancer at doses up to 100 mg/d. Daily dose (mg) Pharmacokinetic analysis showed that E7820 is rapidly B 60 adsorbed following oral administration, with an apparent median terminal elimination half-life of less than 8.6 hours. 50 Hematologic abnormalities (neutropenia and thrombocytopenia) were the most common DLTs. Platelet integrins 40 are necessary for platelet aggregation and clot formation (17). Preclinical studies have shown that oral administration of E7820 induced a dose-dependent reduction in ( µ g h/mL) 30 platelet integrin a-2 expression as measured by flow cyto- 0–24 20 metry, but it did not affect the absolute platelet count (13).

AUG Bleeding episodes did occur in this study in association 10 with thrombocytopenia, and hemorrhagic events will need to be monitored closely in future studies of E7820. The 0 effects of E7820 on platelet function as measured by the 0 50 100 150 200 250 PFA 100 system are being studied in the phase II study of Daily dose (mg) E7820 in combination with cetuximab, and so far no E7820-induced platelet defects have been observed. Other adverse events were generally mild to moderate Figure 1. Maximum plasma concentrations (Cmax) and AUC of E7820 after single doses. A, the indicated amount of E7820 was administered to and reversible. Gastrointestinal (nausea, diarrhea, consti- fasted subjects and plasma E7820 concentrations were determined as pation, abdominal pain, and vomiting) and constitutional

described in the Patients and Methods section. Plasma Cmax were side effects (fatigue) were the most commonly reported C * determined and the mean values (SD) for max after dosing on day 1 ( ) and toxicities with E7820. & day 28 ( ) were calculated. B, the indicated amount of E7820 was Prolonged stable disease was seen at all dose levels but administered to fasted subjects and plasma E7820 concentrations were determined as described in the Patients and Methods section. AUC of was more common at higher doses. Stable disease lasting E7820 was determined and the mean values for AUC after dosing on day 1 greater than 6 cycles was observed in patients with bladder, (*) and day 28 (&) were calculated. colon, carcinoid, melanoma, and non–small cell lung

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targeting angiogenesis. As E7820 is unlikely to cause early 20 tumor shrinkage, measurement of biomarkers such as integrin a-2 expression may instead provide evidence of an early objective vascular response. Our exploratory pharmacody- 10 N = 3 namic analysis suggests that at the MTD, E7820 inhibits the N = 7 N = 4 a N = 2 expression of integrin -2 in a normal tissue surrogate when 0 administered under clinical conditions and that expression of platelet integrin a-2 is readily measurable in patients receiving E7820. These results have been confirmed in a − 10 small dose-escalation study of E7820 administered in combination with cetuximab (19). Larger patient numbers of − patients would be needed to determine whether treatment- 20 N = 3 related decreases in platelet integrin a-2 expression are N = 3 statistically significant and correlate with clinical response. Mean change (% of baselinee value) baselinee of (% change Mean −30 The optimal use of antiangiogenesis agents is likely to be in combination with other chemotherapies or radiotherapy

−40 as shown by the benefit of bevacizumab in combination 10 20 40 70 100 200 with standard chemotherapy in metastatic colorectal and Dose of E7820 lung cancer (20, 21). Potential synergism of E7820 with standard chemotherapy will be investigated in future studies. Cross talk between integrin a-2 expression and EGFR Figure 2. Changes in integrin expression from baseline to day 28. Blood samples were collected predose cycle 1 day 1 and predose cycle 1 day 28. pathways has been shown, and E7820 is now being inves- Diluted blood samples were stained directly with FITC-conjugated anti- tigated in combination with cetuximab in advanced malig- integrin a-2 on antibody and expression levels on platelets were analyzed nancies (22). Preliminary results suggest that the by flow cytometry. Forward scatter and side scatter were used for gating combination is well tolerated and is associated with stable of platelets. The average fluorescent intensity of all patients at predose cycle 1 day 1 and predose cycle 1 day 28 for whom samples were available disease in a proportion of patients (19). is compared at each dose level. Mean percent changes for each dose This trial suggests that up to 100 mg/d of E7820 has a group were calculated using baseline values (set to 100%) obtained for reasonable safety profile and may be associated with disease each subject and compared with follow-up values. The error bars stabilization in a wide variety of heavily pretreated malig- represent standard deviation. nancies. On the basis of these promising findings, E7820 is being now being investigated in a phase II study in combina- cancer. All of these patients had received previous che- tion with the epidermal growth factor inhibitor cetuximab in motherapy and were considered refractory to conventional colorectal cancer (19). Targeting of integrin a-2 expression regimens. The longest duration of stable disease occurred in represents a novel mechanism of inhibiting angiogenesis and a patient with colon cancer who had received 3 prior lines is a promising new strategy in anticancer treatment. of treatment and had documented progressive disease Disclosure of Potential Conflicts of Interest before starting E7820 yet did not show evidence of progression while on treatment with E7820 for 15 months. A.D. Ricart, employment, Pfizer. C. Okereke, I. Krivelevich, D.P. Ros- A lack of objective tumor responses is not unexpected signol, employment, Eisai. E. Rowinsky, employment, ImClone Systems. because antiangiogenic agents may act by slowing tumor The costs of publication of this article were defrayed in part by the payment progression in contrast to conventional cytotoxic che- of page charges. This article must therefore be hereby marked advertisement in motherapeutic agents (18). Traditional measures of anti- accordance with 18 U.S.C. Section 1734 solely to indicate this fact. tumor activity such as radiographically measurable tumor Received January 3, 2010; revised August 23, 2010; accepted August 25, regression are unlikely to be attainable with a single drug- 2010; published online January 5, 2011.

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