Everolimus was generally well toler ated and safety findings were consistent with those from RECORD 1 and from a phase 1 study of everolimus in Chinese patients with advanced solid tumors. This study provides further evidence supporting the use of everolimus as a standard of care Stay Away From
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PTC124 For Good in patients with VEGFr TKI refractory mRCC. Background In the United States, renal cell carcinoma is the seventh and ninth most common form of cancer in men and women, respectively, and a recent report estimates that in 2012, 40,250 men and 24,520 women will be diagnosed with, and 13,570 will die of, this disease. The therapeutic options for RCC have increased consi derably since 2005, due to the availability of seven new agents developed to interrupt the molecular path ways regulating tumor angiogenesis, cell proliferation, and survival.
Treatments of metastatic RCC with these agents, which are inhibitors of vascular endothelial growth factor, VEGF receptors, or mTOR, have a signifi cantly improved survival, but remain palliative. Thus, a cure for metastatic RCC continues to be elusive, but is being pursued actively with various combination strat egies. In this respect, it is noted that the time honored, but not regulatory approved, therapies with interferon alpha have had mixed results in RCC when used in combination with some of these agents. For example, IFN 2b combined with sorafenib achieved an overall response rate of 33% in patients with metastatic disease, IFN 2b combined with temsirolimus was not as ef fective as temsirolimus alone, and IFN combined with bevacizumab significantly increased progression free survival and objective responses.
One major challenge with IFN therapy, either alone or in combin ation, is the frequency with which IFN needs to be administered. Another problem associated with IFN therapy was the adverse events, which include fatigue, fever, nausea, flu like symptoms, and anorexia. While pegylated IFN has allowed for less frequent dosing, many of the same toxic effects remain without appreciable improvement in patient outcome. Inhibition of the mTOR kinase results in the reduction of regulatory proteins involved in the progression of cells from the G1 to S phase of their growth cycle. However, blocking mTOR activity with rapamycin or rapamycin analogs inadvertently acti vates the Akt signaling pathway through an IGF 1R dependent mechanism, which mitigates the anti tumor effects of the mTOR inhibitors. Thus, the combin ation of an anti IGF IR antibody with mTOR inhibitors was shown to block the Akt signaling pathway in rhabdo myosarcoma, breast, and prostate carcinomas, resulting in an additive increase in cell growth inhibition.
Com mon AEs reported in patients treated with everolimus Escape From
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PTC124 Totally included stomatitis, infections, asthenia, fatigue, and diarrhea. common laboratory abnormalities included de creased hemoglobin, increased glucose, and increased cholesterol and triglycerides. pneumonitis occurred in 14% of patients. A phase 1 study investigated everolimus 5 mg and 10 mg daily in Chinese patients with different tumor types, results of which confirmed the safety of everolimus in Chinese patients. Most AEs were grade 1 or 2, and the most common were hypergly cemia, fatigue, and anemia. Based on clinical results, guidelines for the appropriate management of AEs related to everolimus treatment have been developed.
In this study, expected known class effect toxicities re lated to mTOR inhibitor therapy were observed, including anemia, hypertriglyceridemia, hyperglycemia, hypercholes terolemia, pulmonary events, and stomatitis. Most of the AEs were grade 1 2 in severity. Although anemia occurred in 64% of the patients, only 16% and 5% of patients experi enced grade 3 or 4 events, respectively. It is important to note that a large portion of the study population had abnormal hematologic values at baseline, including grades 1 2 decreased hemoglobin in 52% of patients. Many pa tients also had abnormal biochemistry values at baseline, including 44% with increased triglycerides and 28% with increased glucose. Non infectious pneumonitis events occurred in 31% of patients in this study.
Although this percentage was higher than in the overall RECORD 1 population based on blinded investigator assessment, it was similar to the incidence reported based on prospective, blinded independent review of CT scans from patients in the RECORD 1 trial in whom a diagnosis of clinical pneu monitis was not made but who experienced radio graphic changes while receiving everolimus. Additionally, our results were consistent with the incidence of noninfectious pneumonitis reported in the Japanese subpopulation of RECORD 1. In the current study, most pulmonary events were grade 1 or 2. only 6% of patients experienced a grade 3 pulmonary event. In the overall population of RECORD 1, 4% of pa tients experienced a grade 3 pulmonary event and there were no grade 4 events. in the Japanese subpopulation of RECORD 1 there were no grade 3 events. Efficacy outcomes in this study are comparable to those from RECORD 1.
The confirmed objective tumor response rate was 5% in this study versus 1. 8% in RECORD 1. DCR was 66%, which was also comparable to the 69% of patients who achieved PR or SD in RECORD 1. In RECORD 1, everolimus 10 mg daily provided clinical benefit to patients with mRCC whose disease had progressed despite VEGFr TKI ther apy. In comparison, the median PFS asso ciated with everolimus in Chinese patients refractory to previous VEGFr TKI therapy in this single arm study was 6. 9 months.
Grade 3 non infectious pneumonitis was reported in 4 patients, all of whom had lung metastases at study entry 3 events improved to grade 1 2 after steroid therapy, oxygen inhalation, and or dose adjustment. 1 event of pulmonary fibrosis improved to grade 2 following Abstain From
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Ascomycin Totally discontinuation of everolimus. Overall, no grade 4 non infectious pneumonitis was reported. The probability of onset of non infectious pneumonitis was estimated to be 6% at 1 month and 32% at 4 months. The median time to first occurrence of non infectious pneumonitis was not reached. The most frequently observed laboratory abnormalities were decreased hemoglobin, increased triglycer ides, increased fasting glucose, increased cholesterol, and decreased absolute lymphocyte count.
Common grade 3 4 laboratory abnormal ities included decreased hemoglobin, decreased absolute lymphocytes, and increased GGT. Efficacy At the data cut off date, median PFS was estimated to be 6. 9 months. The estimated probability of PFS was 62% at 4 months, 52% at 6 months, and 36% at 12 months. Median OS was not reached. The estimated probability of OS was 76% at 6 months and 56% at 12 months. Confirmed objective tumor responses evaluated by investigator assessment were seen in 3 patients, corre sponding to an ORR of 5%. Stable disease was reported in 39 patients. Everolimus ther apy in this patient population was associated with a DCR of 66%. Pharmacokinetics Mean Cmin after administration of everolimus 10 mg day was 21. 4 12. 4 ng mL at cycle 2, day 1 and 15. 0 9. 97 ng mL at cycle 4, day 1. Mean Cmin after ad ministration of everolimus 5 mg day was 0.
7 ng mL at cycle 2, day 1 and 8. 8 1. 14 ng mL at cycle 4, day 1. Mean Cmin at cycle 4, day 1 at the 10 mg day dose was approximately twice the mean Cmin value at the 5 mg day dose, which confirms a dose proportional increase in pre dose exposure of everolimus after daily administration. In the analysis of PFS, the estimated risk ratio of 0. 67 suggested a trend toward longer PFS with higher time normalized everolimus Cmin. However, the corresponding 95% CI included unity, thereby precluding conclusion of any statistically significant relationship. There was no apparent difference between patients in the evero limus time normalized Cmin categories of 10 ng mL, 10 25 ng mL, and 25 ng mL and all grades of non infectious pneumonitis and stomatitis oral mucositis. Discussion This phase 1b study was planned and conducted to evaluate the safety and efficacy profile of everolimus in Chinese patients with mRCC after failure of VEGFr TKI therapy. Overall safety findings from this study were consistent with those reported in the phase 3 RECORD 1 study and with a phase 1 study conducted in Chinese patients with advanced solid tumors.