Phase I, Pharmacokinetic, and Biological Study of Erlotinib in Combination with Paclitaxel and Carboplatin in Patients with Advanced Solid Tumors

Cancer Therapy: Clinical

PhaseI,Pharmacokinetic,andBiologicalStudyofErlotinibin Combination with Paclitaxel and Carboplatin in Patients with Advanced Solid Tumors Amita Patnaik,1Debra Wood,4 Anthony W. Tolcher,1Marta Hamilton,4 Jeffrey I. Kreisberg,3 Lisa A. Hammond,1Garry Schwartz,2 Muralidhar Beeram,1Manuel Hidalgo,1Monica M. Mita,1 Julie Wolf,4 Paul Nadler,4 and Eric K. Rowinsky1

Abstract Purpose: To assess the feasibility of administeringerlotinib, an inhibitor of epidermal growth factor receptor (EGFR) tyrosine kinase, in combination with paclitaxel and carboplatin, and to identify pharmacokinetic interactions, evaluate downstream effects of EGFR inhibition on surrogate tissues, and seek preliminary evidence for clinical activity. Experimental Design: Patients with advanced solid malignancies were treated continuously with erlotinib at doses of 100, 125, and 150 mg/d orally along with fixed i.v. doses of paclitaxel 225 mg/m2 andcarboplatinAUC6mgÁÁ min/mL, both on day 1every 3 weeks. Results: Twenty evaluable patients were treated with 136 courses of erlotinib, paclitaxel, and carboplatin. Myelosuppression, skin rash, and diarrhea were the principal toxicities. Dose limiting diarrhea occurred in 1of 6 patients at the 100 mgerlotinib dose level, whereas 0 of 9 evaluable patients at the 125 mgerlotinib dose level experienced dose limitingtoxicity and 3 of 5 evaluable patients at150 mgerlotinib experienced dose limitingskin rash and neutropenic sepsis.There was no evidence of pharmacokinetic interactions between paclitaxel and erlotinib; however, total carboplatin exposure trended higher in the presence of erlotinib. No consistent downstream effects on EGFR inhibition were found in skin. Durable objective responses were observed in non ^ small-cell lungand head and neck cancers. Conclusions: A dose level of erlotinib 125 mgcombined with paclitaxel 225 mg/m 2 and carboplatinAUC6mgÁÁ min/mL is recommended for disease-directed studies. This phase I trial was followed by a randomized phase III study in non ^ small-cell lungcancer usinga similar regimen.

The epidermal growth factor receptor (EGFR; ErbB1), a 170- including breast, non–small cell lung (NSCLC), ovarian, kDa plasma membrane glycoprotein, is a member of the colorectal, and head and neck cancers, express EGFR, which is tyrosine kinase receptor family of four closely related receptors: also linked to malignant transformation (3–6). Furthermore, EGFR (ErbB-1), Her2/neu (ErbB-2), Her3 (ErbB-3), and Her4 EGFR gene amplification and rearrangements are frequently (ErbB-4; refs. 1, 2). A vast array of human solid tumors, found in gliomas, whereas activating mutations within the tyrosine kinase domain have now been well described in patients with NSCLC (7–10). Given the importance of EGFR in tumorigenesis, its association with poor prognosis, as well as Authors’ Affiliations: 1Institute for DrugDevelopment, Cancer Therapy and Research Center, 2Brooke Army Medical Center, and 3University of Texas Health response to therapy, it is clearly a rational target for therapeutic Science Center at San Antonio, San Antonio, Texas; and 4OSI Pharmaceuticals, inhibition (3, 5, 11, 12). Inc., Uniondale, NewYork To date, the two major strategies for abrogating EGFR Received 7/31/06; accepted 9/28/06. function have been the use of monoclonal antibodies directed Grant support: Some patients were treated at the Frederic C. Barter Clinical Research Unit of the Audie MurphyVeterans Administration Hospital, San Antonio, against the extracellular domain of the receptor and the use of TX, supported by NIH grant MO1RR01346. quinazolinamine-based small molecules that compete for the The costs of publication of this article were defrayed in part by the payment of page ATP-binding site within the EGFR tyrosine kinase domain. Both charges. This article must therefore be hereby marked advertisement in accordance approaches ultimately result in impairment of the catalytic with 18 U.S.C. Section 1734 solely to indicate this fact. activity of the receptor and its ability to induce downstream Presented, in part, at the 13th Annual Meetingof National Cancer Institute-AACR/ European Organization for Research and Treatment of Cancer, November 2002, signals (13, 14). The small-molecule tyrosine kinase inhibitors Frankfurt, Germany and at the 39th Annual Meetingof the American Society of have differential specificities towards various receptors in the Clinical Oncology, June 2003, Chicago, IL. HER family, with the capacity to block one or more members. Requests for reprints: Amita Patnaik, Institute for DrugDevelopment, Cancer Erlotinib hydrochloride (erlotinib, OSI-774; Tarceva, OSI Therapy and Research Center, 7979 Wurzbach, Suite Z 400, San Antonio, TX 78229. Phone: 210-450-5069; Fax: 210-692-7502; E-mail: [email protected]. Pharmaceuticals, Inc., Melville, NY), a quinazolinamine deriv- F 2006 American Association for Cancer Research. ative, is an orally available reversible and selective inhibitor of doi:10.1158/1078-0432.CCR-06-1886 EGFR tyrosine kinase with an IC50 of 2 nmol/L (0.79 ng/mL)

Clin Cancer Res 2006;12(24) December 15, 2006 7406 www.aacrjournals.org Downloaded from clincancerres.aacrjournals.org on October 2, 2021. © 2006 American Association for Cancer Research. Phase I Trial of Erlotinib, Paclitaxel, and Carboplatin for human EGFR tyrosine kinase in an in vitro enzyme assay of 125 mg qd to more fully characterize the toxicities. The dose of 2 (15, 16). Combination studies of erlotinib and cisplatin done paclitaxel was fixed at 225 mg/m i.v., administered on day 1 and in A549 (human NSCLC) human tumor xenografts have shown repeated every 21 days. The dose of carboplatin was targeted to a fixed ÁÁ synergistic tumor growth inhibition (17). area under concentration-time curve of 6 mg min/mL, administered on The rationale for evaluating the administration of erlotinib day 1 and repeated every 3 weeks. A course was defined as 3 weeks in length. Chemotherapy was continued, according to the disease type, for in combination with paclitaxel and carboplatin includes the a standard number of cycles and thereafter patients were maintained on established role of paclitaxel and carboplatin in NSCLC and erlotinib until disease progression or drug intolerance. Toxicity was ovarian cancer, the distinct spectrum of anticancer activity graded according to the National Cancer Institute Common Toxicity shown with erlotinib in multiple solid tumors (NSCLC, ovary, Criteria (version 2.0). A minimum of three new patients were treated at head and neck), and the widely disparate mechanisms of the first dose level of erlotinib. If dose limiting toxicity (DLT) was not action of these agents. This study was also designed to provide observed in the first three patients, then the dose of erlotinib was the toxicologic and pharmacologic foundation for disease- increased to the next level. If DLT occurred in any of the first three new directed trials. The objectives of this study were to (a) patients in the first course, at least three additional new patients were characterize the principal toxicities of erlotinib administered treated. If no more than one further DLT was encountered, dose once daily in combination with fixed doses of paclitaxel (225 escalation proceeded. Alternately, if DLT was noted in two or more of mg/m2 i.v. every 3 weeks) and carboplatin (AUC 6 mgÁÁ min/mL three additional subjects, dose escalation was to be terminated and the maximum tolerated dose was defined as the highest dose level at which every 3 weeks i.v.) in patients with advanced solid malignan- one third of at least six new patients experienced DLT in course 1. cies; (b) determine the maximum tolerated dose of erlotinib in During the conduct of this trial, there was an option to evaluate an combination with paclitaxel and carboplatin on this dose intervening dose of erlotinib (125 mg qd). Intrapatient dose escalation schedule and recommend doses for subsequent disease- was not permitted. The following events were considered dose limiting directed trials; (c) describe the pharmacokinetics of erlotinib, if attributable to erlotinib exposure: (a) absolute neutrophil count paclitaxel, and carboplatin in combination and determine if <500/AL for longer than 5 days or an absolute neutrophil count there are major effects of erlotinib on the clearance of paclitaxel <1,000/AL associated with fever (temperature z38jC) or infection and carboplatin; (d) seek preliminary evidence of antitumor requiring parenteral antibiotics; (b) platelet count <25,000/AL; (c) any activity in patients with advanced malignancies; and (e) drug-related grade 3 or 4 nonhematologic toxicity, except alopecia, determine whether changes in downstream signaling proteins grade 3 self-limiting fatigue, grade 3 tolerable rash, or diarrhea, nausea, are detectible in surrogate tissue. and vomiting in the absence of optimal supportive medication; (d) inability to complete one 3-week course of therapy due to toxicity; (e) treatment delay >7 days due to unresolved toxicity. Dose reductions of paclitaxel and/or carboplatin were done in Materials and Methods patients with DLT. The dose of either or both agents was reduced, as clinically indicated, to 175 mg/m2 and AUC 5 mgÁÁ min/mL for Patients with histologically confirmed advanced solid malignancies paclitaxel and carboplatin, respectively. Patients who experienced refractory to standard therapy or for whom no effective therapy existed either clinically intolerable or dose limiting skin rash and/or diarrhea were candidates for this study. Eligibility criteria included (a) age of received a maximum of two dose reductions of erlotinib. The dose of z18 years; (b) Eastern Cooperative Oncology Group performance erlotinib was reduced from the 150 and 125 mg dose levels to 100 mg status V2 (ambulatory and capable of self-care); (c) no chemotherapy, followed by 75 mg daily, whereas those patients commencing at a dose radiotherapy, or investigational therapy within the previous 4 weeks of 100 mg daily were reduced to 75 mg followed by 50 mg daily as (6 weeks for nitrosoureas or mitomycin C); (d) adequate hematopoi- indicated for toxicities. etic (absolute neutrophil count z1,500/AL, platelets z100,000/AL, and hemoglobin z9 g/dL), hepatic (total bilirubin V1.5 times the Drug administration institutional normal limits, aspartate aminotransferase and alanine Erlotinib hydrochloride, supplied by OSI Pharmaceuticals as 150, aminotransferase <3.0 times the institutional upper normal limits, 100, and/or 25 mg tablets as the free base, was administered daily on a unless due to hepatic metastases, in which case elevations of <5.0 continuous schedule. Paclitaxel was obtained commercially as a 6 mg/ times the upper normal limits were permitted), and renal (serum mL solution and carboplatin was obtained commercially as a 1 mg/mL creatinine <1.5 times the institutional upper normal limits, or a solution. Both agents were diluted with 250 mL of normal saline before calculated creatinine clearance of z60 mL/min according to the administration. All patients received diphenhydramine (50 mg) and an modified Cockroft and Gault formula) functions; (e) no prior H2 receptor antagonist administered i.v. 30 min before the paclitaxel extensive myelotoxic therapy [defined as >6 courses of alkylating infusion and dexamethasone (20 mg) orally 12 and 6 h before agent–containing chemotherapy (except low-dose cisplatin), mitomy- paclitaxel. Patients received paclitaxel as a 3-h infusion diluted in 500 cin C or a nitrosourea, irradiation to z25% of hematopoietic mL of sterile and isotonic (0.9%, v/v) sodium chloride solution reserves]; (f) no prior exposure to full doses of paclitaxel or (saline). After completion of the paclitaxel infusion, 100 mL of saline carboplatin; (g) no prior exposure to EGFR targeting agents; (h)no were infused over 30 min, followed by an infusion of ondansetron concurrent radiation therapy, chemotherapy, hormonal therapy, or (8 mg) or equivalent serotonin 5-HT3 receptor antagonist diluted in immunotherapy; (i) no significant ophthalmologic conditions (in- 100-mL saline given over 30 min. Thereafter, the total calculated dose cluding keratoconjunctivitis sicca, Sjogren’s syndrome, or disorders of carboplatin, diluted in 500 mL of 5% (weight/volume) dextrose that might increase the risk for epithelium-related complications); and solution, was administered over 30 min. (j) no coexisting medical conditions likely to interfere with study procedures. Written informed consent was obtained according to Pretreatment assessment and follow-up studies federal and institutional guidelines. History, physical examination, and routine laboratory studies were done pretreatment and at least weekly during the first two courses, and Dosage and dose escalation then before each new course. Routine laboratory studies included The starting dose of erlotinib was 100 mg orally daily (qd) from day serum electrolytes, chemistries, renal and liver function tests, complete 3 of the first course without interruption. The dose of erlotinib was blood cell and differential WBC counts, coagulation studies, and escalated to 150 mg qd with the option to evaluate an intervening dose urinalysis. Ophthalmologic evaluations, which included an ophthalmic

www.aacrjournals.org 7407 Clin Cancer Res 2006;12(24) December 15, 2006 Downloaded from clincancerres.aacrjournals.org on October 2, 2021. © 2006 American Association for Cancer Research. Cancer Therapy: Clinical history and slit lamp biomicroscopy, were done pretreatment and then Sections were incubated in primary antibody diluted in 50 mmol/L as clinically indicated. Relevant radiological studies to assess measur- Tris-HCl (pH 7.6), 150 mmol/L NaCl, 0.1% Tween 20 (TBS-T) able and evaluable disease were repeated after every other course with containing 1% ovalbumin and 1 mg/mL sodium azide (12 h), responses scored according to Response Evaluation Criteria in Solid followed by incubations with biotinylated secondary antibody for Tumors criteria (18). Patients were able to continue treatment in the 15 min, peroxidase-labeled streptavidin for 15 min (LSAB-2 System, absence of progressive disease. Dako Corp., Carpenteria, CA), and diaminobenzidine and hydrogen peroxide chromogen substrate (Dako) along with 3,3¶-diaminobenzi- Pharmacokinetic sampling and analytic methods dine enhancer (Signet, Dedham, MA) for 10 min. Slides were To study relevant pharmacokinetic variables reflecting erlotinib, counterstained with hematoxylin and mounted. paclitaxel, and carboplatin exposure, blood was sampled during the Quantitation. The staining intensities for EGFR, phospho-EGFR, first and second courses of treatment. Blood samples were collected for ERK, and phospho-ERK were semiquantitatively assessed on a 0 to 3+ analysis of carboplatin and paclitaxel plasma concentrations on day 1 scale, with <10% staining as 0, 10% to <20% staining as 1+, 20% to of courses 1 and 2 at the following times: before treatment, end of 50% staining as 2+, and >50% staining as 3+. For p27, the grading was infusion, 15, 30, and 60 min and 2, 4, and 6 h after the end of based on the number of cells staining positively for antibody out of infusion, and 24 and 48 h after the start of infusion. Daily 500 cells. administration of erlotinib commenced on day 3, and plasma samples for determination of erlotinib and OSI-420 (principal metabolite) Pharmacokinetic and pharmacodynamic analysis concentrations were obtained pretreatment, 15, 30, and 60 min and 2, Paclitaxel and total platinum pharmacokinetics were examined using 4, 6, and 8 h after dosing, and on days 8 and 15 before dosing. During noncompartmental analytic methods with WinNonLin Enterprise, course 2, plasma samples for erlotinib were obtained pretreatment, 15, version 4.1 software (Pharsight Corp., Mountain View, CA) and actual 30, and 60 min and 2, 4, 6, and 8 h after dosing, as well as on days 2, 3, sample times. The terminal rate constant, Ez, was calculated using 8, and 15 before dosing. For each sample, at least 2 mL of whole blood (at least) three quantifiable time points in each plasma profile. The were collected in heparinized tubes (carboplatin and erlotinib) or AUC0-inf for paclitaxel was calculated using the linear trapezoidal K-EDTA tubes (paclitaxel), kept on ice, and centrifuged within 1 h at method and extrapolated to infinite time using the relationship: AUC E 2,000 Â g for 10 min to isolate plasma. Plasma was frozen immediately extrapolated = Clast/ z (19). The area under the curve for total in cryogenic tubes and stored at VÀ20jC for later analysis. platinum was calculated through the last sample time point, which Plasma samples were analyzed for concentrations of erlotinib and occurred at 48 h following the infusion (AUC0-48). In addition to the metabolite OSI-420 by liquid chromatography-tandem mass noncompartmental analysis, compartmental methods were employed spectrometry methods. Briefly, aliquots of the thawed samples were to determine the a and h half-lives for paclitaxel. A two-compartmental mixed with an internal standard and water and extracted into t-butyl model that assumed first-order elimination was observed to give the methyl ether. The organic layer was evaporated to dryness under best fit based on the fractional coefficients of variation. nitrogen and the residue reconstituted in mobile phase for analysis. For erlotinib and OSI-420, the duration of the plasma sampling Separation of analytes was accomplished by reverse-phase high- following the first dose (study day 3) was determined to be insufficient performance liquid chromatography followed by mass spectrometric for accurate assessment of pharmacokinetic variables. Samples were single reaction monitoring. The lower limit of quantitation was 1.09 collected up to 8 h following the dose, which was too short based on and 1.0 ng/mL for erlotinib and OSI-420, respectively. the f24-h half-life observed for erlotinib in cancer patients. This was Plasma samples were analyzed for concentrations of paclitaxel by use of little consequence to the analysis of the study data because the of a validated liquid chromatography-tandem mass spectrometry erlotinib pharmacokinetic data collected in the presence of concom- procedure. Briefly, aliquots of the thawed samples were mixed with itant paclitaxel and carboplatin dosing were after multiple consecutive an internal standard and methanol and extracted by protein days of erlotinib dosing, when steady-state concentrations would be precipitation. The supernatant was analyzed. Separation of analytes expected. Therefore, for erlotinib and OSI-420, pharmacokinetic was accomplished by reverse-phase high-performance liquid chroma- variables were calculated from the course 2 day 1 plasma sample data tography followed by mass spectrometric selected reaction monitoring. using noncompartmental methods assuming steady state and included The limit of quantitation for the analyte was 5.00 ng/mL. Cmax, Tmax, C24h, and AUC0-24h. AUC0-24h was calculated using the log- Plasma samples were analyzed for concentrations of total platinum linear trapezoidal rule. from carboplatin by use of a validated graphite furnace atomic Statistical analysis absorption (GFAA) procedure. Briefly, aliquots of the thawed samples were transferred to cups and injected directly on GFAA. The limit of Paclitaxel and total platinum pharmacokinetic variables (Cmax and quantitation was 50.00 ng platinum/mL. AUC0-inf or AUC0-48h) on course 1, day 1 and course 2, day 1 were compared within each patient using a paired t test, thus removing Pharmacodynamic assays in skin interpatient variability from the analyses. Given that doses of paclitaxel To assess the pharmacodynamic effects of treatment with an EGFR and carboplatin were not always the same in courses 1 and 2 due to tyrosine kinase inhibitor, normal skin as a surrogate tissue was dose reductions, comparisons of pharmacokinetic variables were made procured for evaluation at baseline and then serially. Biopsies of using dose-normalized values. A significance level of 0.05 was used for normal skin were done pretreatment and before courses 2 and 3. The all analyses. All statistical analyses were done using the SAS version antibodies and immunohistochemical methods used are as follows. 8.2 statistical software program (SAS Institute, Cary, NC). Antibodies. The following antibodies were used: EGFR monoclonal 1173 antibody (Zymed, San Francisco, CA); phospho-EGFR (Tyr ) Results monoclonal antibody (Calbiochem, San Diego, CA); p27 kip1 monoclonal antibody (Zymed); polyclonal anti–phospho-extracellular General signal-regulated kinase (ERK; Thr202/Tyr204) antibody (Cell Signaling Twenty patients, whose pertinent characteristics are summa- Technology, Beverly, MA); and polyclonal ERK1 (C-16, also stains ERK2) antibodies (Santa Cruz Biotechnology, Santa Cruz, CA). rized in Table 1, received 136 total courses of erlotinib, Immunohistochemistry. Sections were heated to 60jC and dehy- paclitaxel, and carboplatin. The total numbers of new patients drated in xylene and graded alcohols. Antigen retrieval was done with and fully evaluable courses at each erlotinib dose level, as well 0.01 mol/L citrate buffer at pH 6.0 at 95jC (for phospho-EGFR, p27, as the rates of DLT as a function of dose level, are detailed in ERK, and phospho-ERK), and proteinase K for 5 min for EGFR. Table 2. Dose reductions, due to toxicity that resulted in patients

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whereas one patient experienced febrile neutropenia in Table 1. Patient characteristics association with a hemorrhagic skin rash. Because the incidence of DLT exceeded the rate predefined for that of Characteristics No. patients the maximum tolerated dose, an intermediate dose level No. patients 20 consisting of erlotinib 125 mg/d, paclitaxel 225 mg/m2, and Median no. courses/patient (range) 6 (2-18) ÁÁ Median age (range), y 55 (22-72) carboplatin AUC 6 mg min/mL was evaluated. No DLTs were Gender (male/female) 15:5 observed in the first three patients treated at this intermediate Median performance status (ECOG) dose level and, therefore, additional patients were enrolled 08with no DLTs among nine patients treated. Therefore, the 112recommended phase II dose level was erlotinib 125 mg/d, Previous treatment 2 ÁÁ Chemotherapy 3 paclitaxel 225 mg/m , and carboplatin AUC 6 mg min/mL. Radiation 5 Chemotherapy and radiation 2 Hematologic toxicity None 10 Myelosuppression, particularly neutropenia, was the princi- Primary tumor sites pal hematologic toxicity of the erlotinib/paclitaxel/carboplatin Lung (non – small cell) 11 Head and neck 3 regimen. The median, range, and distribution of the nadir Breast 2 absolute neutrophil count and platelet counts as a function of Bladder, thyroid, penile, colorectal 1 each dose level are displayed in Table 3. The absolute neutrophil count nadir during the first course typically occurred between Abbreviation: ECOG, Eastern Cooperative Oncology Group. days 6 and 14 (median 13 days), with recovery by the planned start date of the second course. Neutropenia of grade 3 or 4 severity occurred in 48 of 136 (35%) courses and was of dose being treated with multiple intermediate dose levels, are limiting severity in 3 (2%) courses. Thrombocytopenia with a outlined in Table 2. Eleven patients continued to receive platelet count <25,000/AL was observed in 2 of 136 (1.5%) erlotinib alone after treatment with the study regimen. courses, with both instances occurring beyond the first course. Erlotinib dose escalation proceeded in the following The first cohort (erlotinib 100 mg, paclitaxel 225 mg/m2, and manner. Six new patients were treated at the first dose level carboplatin AUC 6 mgÁÁ min/mL) was associated with brief grade of 100 mg erlotinib with paclitaxel 225 mg/m2 and 3 or 4 neutropenia in 15 of 33 (45%) evaluable courses whereas carboplatin AUC 6 mgÁÁ min/mL. One of six patients at the one patient experienced prolonged neutropenia in the first first dose level experienced DLT, having grade 3 diarrhea course and another experienced grade 4 neutropenia with fever despite optimal supportive therapy, which was attributed to in course 3. A total of 26 courses were administered in the erlotinib exposure. Another patient had grade 4 neutropenia second cohort (erlotinib 150 mg, paclitaxel 225 mg/m2, and longer than 5 days; however, this did not meet the protocol carboplatin AUC 6 mgÁÁ min/mL), of which three were associated criteria for DLT because it was felt to be an expected effect of with grade 3 neutropenia, five with brief grade 4 neutropenia, the cytotoxic therapy rather than erlotinib. Dose escalation of one with grade 4 neutropenia and fever, and one with a platelet erlotinib was permitted if two or fewer DLTs occurred in a count <25,000/AL. The third cohort (erlotinib 125 mg, cohort of six patients, and thus the next dose level explored paclitaxel 225 mg/m2, and carboplatin AUC 6 mgÁÁ min/mL) was 150 mg erlotinib with paclitaxel 225 mg/m2 and was complicated by transient grade 3 or 4 neutropenia in 25 of carboplatin AUC 6 mgÁÁ min/mL. Two of five patients treated 77 courses, prolonged neutropenia in one course, and a platelet at the second dose level experienced intolerable grade 3 rash, count <25,000/AL in one course.

Table 2. Dose escalation scheme

Dose levels Cohort No. new patients Patients reduced Total patients/ New patients with DLT/ to this dose no. courses total new patients Erlotinib Carboplatin AUC Paclitaxel (mg) (mgÁÁmin/mL) (mg/m2) 100 6 225 1 6 1 7/20 1/6 125 6 225 3 9 0 9/32 0/9 150 6 225 2 5 0 5/8 3/5 50 6 175 — 0 1 1/3 — 75 6 175 — 0 1 1/1 — 75 6 225 — 0 2 2/6 — 100 6 175 — 0 2 2/7 — 100 5 175 — 0 1 1/1 — 100 5 225 — 0 1 1/2 — 125 6 175 — 0 2 2/4 — 125 5 175 — 0 2 2/3 — 150 6 175 — 0 1 1/2 — 100 0 0 — 0 4 4/8 — 125 0 0 — 0 5 5/35 — 150 0 0 — 0 2 2/4 —

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Table 3. Hematologic toxicity

Erlotinib No. patients No. courses (first courses)with toxicity No. patients with heme dose level/ (courses) DLT in first course*/ cohort (mg) total patients Neutropenia Thrombocytopenia Median nadir Gr. 3 Gr. 4 Gr. 4, Gr. 3-4 Median Platelets Grade ANCc >5 d and fever nadir <25,000 4 plateletsc (ML) 100/1 6 (33) 290 (60-790) 9 (0) 6 (2) 1 (1)b 1 (0) 95 (29-184) 0 (0) 0 (0) 0/6 125/3 9 (77) 390 (30-980) 10 (2) 15 (1) 1 (1)b 0 (0) 119 (21-194) 1 (0) 0 (0) 0/9 150/2 5 (26) 610 (40-1,480) 3 (1) 5 (1) 0 (0) 1 (1) 120 (15-167) 1 (0) 0 (0) 1/5

Abbreviations: ANC, absolute neutrophil count; heme, hematologic; Gr, grade. *Toxicities were defined as dose limiting if attributed to erlotinib exposure. cMedian values (ranges) for all courses. Values expressed as AL (range). bProlonged neutropenias in both cases were attributed to cytotoxic therapy rather than to erlotinib and therefore not scored as dose-limiting toxicities

Nonhematologic toxicity One patient experienced grade 3 diarrhea in cohort 1 in spite of Nonhematologic toxicities were mild to moderate in severity optimal supportive care and required two successive dose in most patients. Cutaneous toxicity and diarrhea were the most reductions of erlotinib. A second patient in cohort 3 (erlotinib common toxicities observed with this regimen and were dose 125 mg/d) experienced grade 3 diarrhea in course 3, which limiting in three patients. The distributions of nonhematologic responded to supportive management. Nausea and vomiting toxicities as a function of both grade and dose level are listed in were also observed in patients treated with erlotinib, paclitaxel, Table 4. and carboplatin but were not dose limiting. Grade 1 and/or Cutaneous toxicity, which was experienced by 18 of 20 2 nausea or vomiting occurred in 22 (16%) and 12 (9%) of (90%) evaluable patients, was generally asymptomatic or 136 courses, respectively, and was typically managed with minimally symptomatic. Intolerable grade 3 skin rash was phenothiazines or serotonin 5-HT3 receptor antagonists. observed in two patients who received treatment with erlotinib Other toxicities which were not dose limiting included 150 mg/d; one of these individuals developed a hemorrhagic peripheral neuropathy, fatigue, arthralgia, myalgia, dysgeusia, rash. Grade 1 or 2 rash occurred in 70% of courses with 19 of and weight loss. 33 (58%) courses affected in cohort 1, 16 of 26 (62%) courses affected in cohort 2, and 61 of 77 (79%) courses affected in cohort 3. The rash typically involved the face and upper trunk Antineoplastic activity and was characterized by maculopapular and pustular acnei- Three confirmed partial responses were observed. Partial form lesions on an erythematous base. The onset of rash was responses were noted in two previously untreated patients with often within the first 10 days of treatment, with some patients metastatic NSCLC who received treatment as part of the first resolving gradually over weeks and others continuing through- and third cohorts (erlotinib doses of 100 and 125 mg, out all cycles. The use of supportive agents, including topical respectively). The response durations were 7 and 12 months. and systemic corticosteroids and antibiotics, was permitted A partial response lasting 8 months was also observed in a 51- and, in some cases, ameliorated symptoms. Diarrhea occurred year-old previously untreated female with head and neck in 11 patients and was characterized as loose or watery stools cancer. The patient was treated with erlotinib 125 mg/d, without blood, mucous, fever, or tenesmus. Grade 1 or 2 paclitaxel 225 mg/m2, and carboplatin AUC 6 mgÁÁ min/mL. diarrhea occurred in 35 of 136 (26%) courses and was either Stable disease for 9 months was observed in two previously self-remitting or improved following the use of loperamide. untreated patients with NSCLC and head and neck cancer.

Table 4. Nonhematologic toxicity

No. courses (first courses)with toxicity Erlotinib dose level/ No. patients Rash Diarrhea Nausea Vomiting Neuropathy Fatigue Arth/myal cohort (mg) (courses) grade grade grade grade grade grade grade 1-2 3 1-2 3 1-2 3 1-2 3 1-2 3 1-2 3 1-2 3 100/1 6 (33) 19 (4) 0 (0) 13 (1) 1 (1) 5 (1) 0 (0) 4 (1) 0 (0) 15 (3) 1 (0) 10 (2) 0 (0) 7 (1) 0 (0) 125 9 (77) 61 (7) 0 (0) 16 (4) 1 (0) 15 (4) 1 (0) 7 (0) 1 (0) 44 (2) 0 (0) 6 (1) 1 (0) 16 (7) 0 (0) 150 5 (26) 16 (1) 2 (2) 6 (1) 0 (0) 2 (1) 1 (0) 1 (1) 1 (0) 18 (2) 0 (0) 3 (0) 1 (1) 4 (3) 2 (0)

Abbreviations: Arth, arthralgias; Myal, myalgias.

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Fig. 1. Paired paclitaxel Cmax and AUC0-inf values for individual patients in the absence (course1)and presence (course 2) of erlotinib. Dotted lines denote patients whose doses were reduced in course 2.

Pharmacokinetics the presence and absence of erlotinib (P = 0.69) among 16 Plasma samples for pharmacokinetic studies were obtained patients for whom data from both courses were available, from 19 patients for paclitaxel, carboplatin, and erlotinib, although AUC0-48h values were significantly higher, 10.6% on principally to detect relevant drug-drug interactions. Figures 1 average, in the presence of erlotinib (P = 0.02). Figure 3 shows and 2 display Cmax and AUC values for paclitaxel and platinum, dose-normalized erlotinib steady-state Cmax and AUC0-24h respectively, in the presence and absence of erlotinib. A one- values in the presence and absence (historical data) of sample (paired) t test was done to compare dose-normalized paclitaxel and carboplatin. Paired t tests were done to compare Cmax and AUC values between course 1 (without erlotinib) and steady-state AUC0-24h and Cmax values between the present course 2 (with erlotinib). For paclitaxel, there were no study and the historical monotherapy data (20). Data were significant differences in dose-normalized Cmax (P = 0.17) or available from 16 patients following erlotinib administration in AUC0-inf (P = 0.14) among 18 patients for whom data from the presence of carboplatin and paclitaxel for Cmax and from 13 both courses were available. There were no significant differ- patients for AUC0-24h. The historical data set for erlotinib Cmax ences between dose-normalized total platinum Cmax values in and AUC0-24h as monotherapy consisted of data from 24 and

Fig. 2. Paired total platinum Cmax and AUC0-48h for individual patients in the absence (course1)and presence (course 2) of erlotinib. Dotted lines, patients whose doses were reduced in course 2.

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Fig. 3. Dose normalized erlotinib steady-state Cmax and AUC0-24h in the presence and absence (historical) of concomitant paclitaxel and carboplatin. Abbreviations: E, erlotinib; P, paclitaxel; C, carboplatin; AUC0-24h, Area under the curve for erlotinib that was calculated through the last sample time point, which occurred at 24 h post-treatment.

23 patients, respectively. There were no significant differences Dose-normalized pharmacokinetic variables reflecting drug in erlotinib dose-normalized Cmax (P = 0.94) or AUC0-24h (P = exposure were used because there were dose reductions of 0.38) when administered with and without paclitaxel and both erlotinib and chemotherapy for some patients between carboplatin. Similar results were obtained for OSI-420, with P courses 1 and 2. Although the pharmacokinetics of paclitaxel values for the differences between erlotinib monotherapy and were not significantly different in the presence and absence of combination therapy being 0.95 and 0.78. erlotinib, the shown results for carboplatin are less clear. Whereas the carboplatin Cmax values were not significantly Correlative studies in skin different between courses 1 and 2, AUC0-48h values increased Serial samples of normal skin were obtained in 12 patients to by 10.6%, on average, in course 2 (P = 0.02). Nevertheless, assess the effects of erlotinib on EGFR and downstream considerations in interpreting these results should include the signaling proteins. There were no consistent effects shown in fact that only total platinum, instead of both total and free expression of EGFR, phospho-EGFR, ERK, or phospho-ERK platinum concentrations, was measured, and some patients following treatment with the investigational regimens. The received dose reductions of paclitaxel and erlotinib in course expression of p27 increased in eight patients following 2. From a clinical perspective, however, it is unlikely that the treatment with erlotinib, and two of these patients had higher exposure to total platinum affected the ability to confirmed partial responses. administer carboplatin because only two patients required dose reduction due to myelosuppression following course 1. There was no significant difference in pharmacokinetic Discussion variables reflecting erlotinib exposure (Cmax and AUC0-24h) observed following concomitant administration of erlotinib Aberrant EGFR expression is detected in many solid tumors with paclitaxel and carboplatin and those resulting from and is associated with poor disease outcome (1–3). EGFR patients receiving erlotinib monotherapy (historical data; activation can promote a malignant phenotype and was ref. 20). therefore identified as an attractive therapeutic target for The results of this phase I and pharmacokinetic study anticancer drug development. The rationale for the combina- indicate that daily treatment with erlotinib in combination tion of erlotinib with carboplatin and paclitaxel was based on with paclitaxel and carboplatin administered every 3 weeks i.v. favorable interactions between erlotinib and platinum com- is feasible and generally well tolerated over multiple cycles. The pounds shown in preclinical studies and the known single maximum dose of erlotinib that could be administered with agent activity of erlotinib in NSCLC, ovarian cancer, and head full doses of paclitaxel and carboplatin was 125 mg/d. and neck cancer, all of which are known to respond to Although erlotinib could not be administered at the standard platinum-based therapies (16, 17). single-agent dose of 150 mg/d in this combination study, skin This phase I, pharmacologic, and biological study was rash, a potential surrogate marker of activity, was observed designed to evaluate the feasibility of administering erlotinib consistently at the 125 mg dose level (21). The tolerance of a daily with paclitaxel and carboplatin given i.v. every 3 weeks. similar regimen was substantiated in a phase III study of 1,059 The principal toxicities of this regimen were neutropenia, skin patients with advanced NSCLC receiving first-line therapy rash, and diarrhea, although hematologic toxicity was attrib- consisting of paclitaxel and carboplatin with or without uted predominantly to the effects of cytotoxic therapy rather erlotinib (TRIBUTE—Tarceva responses in conjunction with than erlotinib. Repeated administration of the regimen at its paclitaxel and carboplatin; ref. 22). No survival benefit or recommended phase II dose level (erlotinib 125 mg/d, improvement in response rate versus chemotherapy alone was paclitaxel 225 mg/m2, and carboplatin AUC 6 mgÁÁ min/mL) observed in this trial. Some notable differences in the doses was tolerable. of erlotinib and paclitaxel were, however, apparent in this

Clin Cancer Res 2006;12(24) December 15, 2006 7412 www.aacrjournals.org Downloaded from clincancerres.aacrjournals.org on October 2, 2021. © 2006 American Association for Cancer Research. Phase I Trial of Erlotinib, Paclitaxel, and Carboplatin

study. Patients received 200 mg/m2 of paclitaxel instead of 225 Institute of Canada BR.21), resulting in the regulatory mg/m2 used in the current phase I study, possibly accounting approval of erlotinib in the United States and worldwide for better hematologic tolerance and, furthermore, the ability (26). The negative results of randomized phase III trials of to administer the standard single-agent dose of erlotinib (150 chemotherapy and EGFR tyrosine kinase inhibitors in mg). There are several reasons why the current phase I study advanced NSCLC suggest that the concurrent administration failed to show tolerance of the 150 mg erlotinib dose level, of small-molecule EGFR tyrosine kinase inhibitors does not including the fact that all five patients evaluated at this dose augment standard cytotoxic therapeutic regimens in unselect- level had received prior therapy, thus representing a more ed patients. Evaluation of determinants of activity and extensively pretreated population compared with the TRIBUTE alternate schedules and/or sequential administration of agents study, in which patients had not received prior chemotherapy may be warranted given the single-agent activity of erlotinib in for advanced disease. In addition, patients in the current phase NSCLC. Furthermore, as increasing data become available on I trial received higher doses of paclitaxel consistent with a more the presence of EGFR tyrosine kinase domain mutations, this aggressive but arguably less well tolerated regimen used for will need to be taken into consideration in the design of NSCLC. Furthermore, as with all limited data sets, greater future clinical trials to select patients with EGFR dependence. variations in results are possible due to a small sample size. Pathway dependence was pivotal in the studies that confirmed The current phase I study was important as it showed the the efficacy of trastuzumab in patients with metastatic breast feasibility of administering paclitaxel and carboplatin with cancer, a finding which might otherwise have been missed in erlotinib. Randomized phase III trials have, however, failed to a population unselected for HER2/neu amplification (27, 28). show benefit for the addition of small molecules to The CALGB-30406 trial has used a regimen involving chemotherapy regimens in NSCLC. Along with the TRIBUTE paclitaxel, carboplatin, and erlotinib to determine activity in study, three additional trials of chemotherapy in combination a chemotherapy-naBve select population of patients with stage with EGFR tyrosine kinase inhibitors have yielded negative IIIB or IV NSCLC in comparison with erlotinib alone and results in advanced NSCLC although none of these studies relationships between EGFR mutations and end points selected patients on the basis of EGFR dependence (23–25). reflecting clinical benefit will be evaluated. Future studies Erlotinib administered as a single agent after first- or second- evaluating the combination of erlotinib, paclitaxel, and line chemotherapy has, however, shown survival benefit in carboplatin should also be considered for other solid tumors, NSCLC in comparison with placebo (National Cancer including ovarian and head and neck cancers.

References 1. Olayioye MA, Neve RM, Lane HA, Hynes NE.The ErbB tumors to gefitinib and erlotinib. Proc Natl Acad Sci 21. Perez-Soler, Saltz L. Cutaneous adverse effects signaling network: receptor heterodimerization in U S A 2004;101:13306^11. with HER1/EGFR-targeted agents: is there a silver development and cancer. EMBOJ 2000;19:3159 ^ 67. 11. Arteaga CL,Truica CI. Challenges in the development lining? J Clin Oncol 2005;23:5235 ^ 46. 2. Yarden Y. The EGFR family and its ligands in human of anti-epidermal growth factor receptor therapies in 22. Herbst RS, Prager D, Hermann R, et al. TRIBUTE cancer. Signalling mechanisms and therapeutic breast cancer. Semin Oncol 2004;31:3 ^ 8. Investigator Group. TRIBUTEöa phase III trial of opportunities. Eur J Cancer 2001;37:S3^ 8. 12. Yarden Y, Slowkowski MX. Untangling the ErbB erlotinib HCL (OSI-774) combined with carboplatin 3. Salomon DS, Brandt R, Ciardiello F, Normanno N. signaling network. Nat Rev Mol Cell Biol 2001;2: and paclitaxel chemotherapy in advanced non-small Epidermal growth factor-related peptides and their 127 ^ 37. cell lungcancer (NSCLC). J Clin Oncol 2005;23: receptor in human manignancies. Crit Rev Oncol 13. Toldeo LM, Lyndon NB, Elbaum D. The structure- 5856^8. Hematol 1995;19:183 ^232. based design of ATP-site directed protein kinase 23. Herbst RS, Giaccone G, Schiller JH, et al. Gefitinib 4. Cornianu M, Tudose N. Immunohistochemical inhibitors. Curr Med Chem 1999;6:755 ^ 805. in combination with paclitaxel and carboplatin in ad- markers in the morphological diagnosis of lung carci- 14. Al-Abeidi F, Lam KS. Development of inhibitors vanced non-small cell lungcancer. A phase III trial- noma. Rom J Morphol Embryol 1997;43:181 ^ 91. for protein tyrosine kinases. Oncogene 2000;19: INTACT 2. J Clin Oncol 2004;22:785 ^ 94. 5. Fox SB, Harris AL. The epidermal growth factor 5690^701. 24. Giaccone G, Herbst RS, Manegold C, et al. Gefitinib receptor in breast cancer. J Mammary Gland Biol 15. MoyerJD, Barbacci EG, Iwata KK, et al. Induction of in combination with gemcitabine and cisplatin in Neoplasia 1997;2:131 ^ 41. apoptosis and cell cycle arrest by CP-358,774, an advanced non-small cell lungcancer: a phase III trial- 6. Ke LD, Adler-Storthz K, Clayman GL, YungAW, inhibitor of epidermal growth factor receptor tyrosine INTACT1. J Clin Oncol 2004;22:777^ 84. Chen Z. Differential expression of epidermal growth kinase. Cancer Res 1997;57:4838^48. 25. Gatzemeier U, Pluzanska A, Szczesna A, et al. factor receptor in human head and neck cancers. Head 16. OSI Pharmaceuticals, Inc., Genentech Inc., and F. Results of a phase III trial of erlotinib (OSI-774) com- Neck 1998;20:320^ 7. Hoffmann-La Roche Ltd. Clinical Investigator’s Bro- bined with cisplatin and gemcitabine (GC) chemo- 7. Wilkstrand CJ, Reist CJ, Archer GE, Zalutsky MR, chure. 8th ed. 2004. therapy in advanced non-small cell lungcancer Bigner DD. The class III variant of the epidermal 17. Higgins B, Kolinsky K, Smith M, et al. Antitumor (NSCLC) [abstract 7010]. ProcAm Soc Clin Oncol growth factor receptor (EGFRvIII); characterization activity of erlotinib (OSI-774, Tarceva) alone or in 2004;23:617. and utilization as an immunotherapeutic target. J Neu- combination in human non-small cell lungcancer tu- 26. Shepherd FA, Rodrigues Pereira J, et al. National rovirol 1998;4:148^58. mor xenograft models. Anticancer Drugs 2004;15: Cancer Institute of Canada ClinicalTrials Group. Erloti- 8. LynchTJ, Bell DW, Sordella R, et al. Activatingmuta- 503^12. nib in previously treated non-small-cell lungcancer. tions in the epidermal growth factor receptor underly- 18. Therasse P. Response Evaluation Criteria in Solid N Engl J Med 2005;353:123 ^ 32. ingresponsiveness of non-small-cell lungcancer to Tumors. Eur J Cancer 2002;38:1817^ 23. 27. Vogel CL, Cobleigh MA, Tripathy D, et al. Efficacy gefitinib. N Engl J Med 2004;350:2129 ^ 39. 19. Gibaldi M, Perrier D. Pharmacokinetics. 2nd ed. and safety of trastuzumab as a single agent in first-line 9. Paez JG, Janne PA, Lee JC, et al. EGFR mutations in NewYork: Marcel Dekker; 1982. p. 445 ^ 9. treatment of HER2-overexpressingmetastatic breast lungcancer. Correlation with clinical response to gefi- 20. HidalgoM,SiuLL,NemunaitisJ,etal.PhaseIand cancer.JClinOncol2002;20:719^26. tinib therapy. Science 2004;304:1497^500. pharmacologic study of OSI-774, an epidermal 28. Slamon DJ, Leyland-Jones B, Shak S, et al. Use of 10. Pao W, Miller V, Zakowski M, et al. EGF receptor growth factor receptor tyrosine kinase inhibitor, in chemotherapy plus a monoclonal antibody against gene mutations are common in lung cancers from patients with advanced solid malignancies. J Clin HER2 for metastatic breast cancer that overexpresses ‘‘never smokers’’and are associated with sensitivity of Oncol 2001;19:3267 ^ 79. HER2. N Engl J Med 2001;344:783 ^ 92.

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Amita Patnaik, Debra Wood, Anthony W. Tolcher, et al.

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