A Phase I Study of Swainsonine in Patients with Advanced Malignancies1
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[CANCER RESEARCH 54, 1450-1457, March 15, 1<»4] A Phase I Study of Swainsonine in Patients with Advanced Malignancies1 Paul E. Goss2, Jose Baptiste, Berny Fernandes, Michael Baker, and James W. Dennis3 Toronto Hospital, Department of Medical Oncology, Faculty of Medicine ¡P.E. G., M. B.¡,and Department of Molecular & Medical Genetics [J. B., J. W. £>./,University of Toronto; and Samuel Lunenfeld Research Institute, Mount Sinai Hospital [B. E, J. W. £>./,Toronto, Ontario, M5G 1X5 ABSTRACT Furthermore, inhibitors of JV-linked oligosaccharide processing such as castanospermine and swainsonine have been shown to attenuate Swainsonine, an a-mannosidase inhibitor which blocks Golgi oligosac- both metastasis and tumor growth in animal models (8-11). charide processing, represents a new class of compounds that inhibit both Swainsonine is an indolizidine alkaloid found in Australian Swain- rate of tumor growth, and metastasis, in murine experimental tumor models. In this first phase I study, the quantitative and qualitative toxici- sona canescens (12), North American plants of the genera Astragalus ties of Swainsonine have been studied in patients given a continuous i.v. and Oxytropis (13), and also in the fungus Rhizoctonia leguminocola infusion over 5 days, repeated at 28-day intervals. Dose levels were esca (14). The alkaloid is a potent inhibitor of the Golgi enzyme a-man lated in increments of 100 ¿ig/kg/day from 50-550 jug/kg/day. Nineteen nosidase II (15), an enzyme required for maturation of TV-linked oli patients with both solid tumor and hematological malignancies were given gosaccharides on newly synthesized glycoproteins. Swainsonine also a total of 31 courses. Hepatotoxicity, particularly in patients with liver blocks lysosomal a-mannosidases causing the accumulation of oligo métastases,was the dose-limiting toxicity. The maximum tolerated dose mannoside chains in cells exposed to the drug (16). T24H-ras-trans- iMTDi and the recommended starting dose (MTD -1 level) were 550 and fected NIH 3T3 cells lose their ability to grow in an anchorage- 450 /ig/kg/day, respectively. Common side effects included edema, mild independent manner when cultured in the presence of swainsonine liver dysfunction, a rise in serum amylase, and decreased serum retino!. (17), suggesting induction of a more differentiated phenotype. The Acute respiratory distress syndrome possibly precipitated by swainsonine autocrine-dependent growth rate of murine and human tumor cell lines resulted in a treatment-related death in a patient with significant pretreat in vitro is reduced by swainsonine (18, 19). Swainsonine-treated ment hepatic dysfunction. One patient with head and neck cancer showed >50% shrinkage of tumor mass for 6 weeks after treatment. Two patients MDAY-D2 lymphoma tumor cells show reduced adhesion to endo- with lymphangitis carcinomatosis on chest X-ray noted improvement in thelial cells in vitro and in vivo (20), and swainsonine blocks invasion cough and shortness of breath during the infusion of swainsonine and for of murine and human tumor cells through extracellular matrix while 1 week thereafter. enhancing cell adhesion to extracellular matrix proteins in vitro Clearance and serum half-life for swainsonine were determined to be (21, 22). approximately 2 ml/h/kg, and 0.5 day, respectively. Golgi oligosaccharide In animals, swainsonine exhibits antitumor activity when given p.o. processing, a putative anticancer target for swainsonine was inhibited in (8, 23, 24), by i.p. injection (25), and by systemic infusion (18). For peripheral blood lymphocytes as evidenced by a marked decrease in leu- example, swainsonine administered to athymic nude mice in drinking koagglutinin binding after 5 days of treatment. Oligomannosides in pa tient urine increased 5-to 10-fold over the 5 days of treatment, indicating water inhibited the growth rate of human colorectal carcinoma and that tissue lysosomal a-mannosidases were also blocked by swainsonine. MeWo melanoma tumor xenografts by 50% (18, 19). The growth of Urine oligomannoside accumulation reached steady state at 3 days, ap murine Sarcoma 180 ascites tumors was completely inhibited by 30 proximately 1 day after serum drug levels reached steady state. The and 100 mg/kg/day administered i.p. for 5 consecutive days after fraction of HLA-DR-positive cells in peripheral blood lymphocytes in tumor cell inoculation (25). Swainsonine p.o. at 10 /J-g/ml in the creased following 5 days of swainsonine treatment, an effect similar to that drinking water of athymic nude mice showed additive antitumor ac observed for peripheral blood lymphocytes from normal subjects cultured tivity with a interferon, such that human HT29m colon carcinoma with swainsonine. No significant changes in CD3, CD4, CDS, CD16, and xenografts grew at one-tenth the rate of those in untreated mice (18). CD25 were observed. Swainsonine produces minimal toxicity when ad The action of swainsonine as an immune modulator has been re ministered i.v. to cancer patients at dosages that inhibit both Golgi a-man viewed (23, 26). When given p.o. to mice, the alkaloid alleviates nosidase II and lysosomal a-mannosidases. Detection of hepatic métasta chemically and tumor-induced immune suppression (25, 27, 28), ses or liver enzyme abnormalities prior to treatment predict for more stimulates lymphocyte proliferation (29) and NK4 cell activity (23), significant toxicity. and activates macrophages (30, 31). The drug also stimulates LAK cell activity when added to cultures of human lymphoid cells (32). Preclinical toxicology studies in rodents showed swainsonine to be INTRODUCTION well tolerated (18, 33, 34). No mortality occurred in young rats given Malignant transformation in rodent and human tumors is associated swainsonine at doses up to 46 mg/kg/day by miniosmotic pump for with increased branching at the trimannosyl core of complex-type periods of 3 weeks (34). The drug suppressed the growth rate of young asparagine (A^-linked oligosaccharides (1-3). We have shown that the rats apparently by suppression of appetite, and caused lysosomal degree of ß1-6branching in rodent tumor models (3, 4) and in human storage of oligosaccharides in tissues including the central nervous breast and colon carcinomas (5, 6) correlates with disease progression. system. However, no evidence of neurotoxicity was noted in this or More importantly, we have demonstrated that somatic mutations other preclinical studies on rodents treated with swainsonine (19, 34). which inhibit oligosaccharide processing in the Golgi dramatically In this first phase I study, cancer patients were given courses of inhibit métastasesand reduce solid tumor growth in mice (4, 7). continuous 5-day i.v. infusions of swainsonine in escalating doses from 50-550 /xg/kg/day repeated every 28 days. The starting dose level of 50 pig/kg/day was an estimate of the p.o. dosage which had Received 8/9/93; accepted 1/14/94. The costs of publication of this article were defrayed in part by the payment of page antitumor activity in mice (18, 19, 23). The schedule of a 5-day charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. ' This work was supported in part by research grants from National Cancer Institute of 4 The abbreviations used are: NK, natural killer; LAK, lymphocyte-activated killer: Canada to J. W. D., and by a grant from the Mount Sinai Hospital for the purchase of AST, aspartate aminotransferase; MTD, maximum tolerated dose; FACE, fluorphore- swainsonine. assisted carbohydrate electrophoresis; FACS, fluorescence-activated cell sorter; PEL, 2 To whom requests for reprints should be addressed, at The Toronto Hospital. MLW peripheral blood lymphocytes; L-PHA, phylohemagglutinin; IL, interleukin; TNF, tumor 2-022, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4. necrosis factor; FITC, fluorescein isothiocyanate; ALT, alanine aminotransferase; Glc- 3 Senior Research Scientist of the National Cancer Institute of Canada. NAc, /V-acetylglucosasmine; Man, mannose. 1450 Downloaded from cancerres.aacrjournals.org on September 29, 2021. © 1994 American Association for Cancer Research. SWAINSONINE IN ADVANCED MALIGNANCIES infusion given every 28 days was based primarily on the antitumor of nitrogen at 60°C.The residue was further dried in a desiccator over P2O5 at activity noted in mice given a 24-h exposure to swainsonine in an room temperature for 12 h. interrupted twice weekly schedule (24). The limitations of adminis To the dry samples were added 1 ml of dry acetonitrile, 15 mg of 4-dimeth- tering an in-hospital 5-day infusion to patients with advanced malig ylaminopyridine, and 15 mg of sodium acetate. The samples were cooled to 0°Cand 0.5 ml of acetic anhydride was added and left overnight at room nancies more often than once monthly were also taken into consider temperature. The acetylated reaction products were then partitioned between 1 ation. The data on toxicity, serum drug levels, Golgi and lysosomal a-mannosidase inhibition, and lymphocyte marker changes are in ml of chloroform and 1 ml of distilled water with gentle shaking of the samples. Polar contaminants dissolve in the aqueous layer, whereas the acety cluded in this report. lated saccharides and swainsonine dissolve in the lower chloroform layer. The chloroform layer was washed with 1 ml of water, and traces of water and acetic anhydride were removed by passing the samples over 500-mg cartridges of basic alumina (Alltech Inc.). The solvent