A phase I study of afatinib combined with paclitaxel and bevacizumab in patients with advanced solid tumors

Long-term benefit of afatinib combined with bevacizumab in a lung adenocarcinoma patient with a novel rare EGFR Q787L mutation

BACKGROUND

The epidermal growth factor receptor (EGFR) is among the most frequently mutated genes in lung adenocarcinomas (LUAC). The combination of afatinib and bevacizumab has primarily been reported in LUAC cases exhibiting resistance to EGFR tyrosine kinase inhibitors (EGFR-TKI), particularly in classical variants such as EGFR exon 19 deletions and the L858R mutation in exon 21. However, the clinical efficacy of afatinib combined with bevacizumab in treating rare EGFR mutations remains underexplored.

CASE PRESENTATION

We present a case of T4N0M0 stage IIIA LUAC in which disease progression occurred following tumor resection and subsequent chemotherapy combined with bevacizumab. Next-generation sequencing of peripheral blood identified a novel and rare EGFR exon 20 Q787L mutation. Maintenance therapy with icotinib, a first-generation EGFR-TKI, combined with bevacizumab was initiated, but the patient developed resistance to icotinib after 8 months. No drug availability variants or acquired resistance-related mutations were detected. Subsequently, maintenance therapy with oral afatinib plus bevacizumab was initiated, resulting in partial remission after 3 months. As of the most recent CT scan in November 2023, the patient has achieved a progression-free survival (PFS) of 56 months on afatinib plus bevacizumab maintenance therapy, representing the longest reported duration to date, with no severe side effects observed.

CONCLUSION

Our findings suggest that the combination of afatinib and bevacizumab may offer long-term clinical benefits for LUAC patients harboring the novel and rare EGFR Q787L mutation. This case highlights a potential therapeutic strategy warranting further investigation in clinical studies.

Recent Research Progress of Chiral Small Molecular Antitumor-Targeted Drugs Approved by the FDA From 2011 to 2019

Chiral drugs usually contain chiral centers, which are present as single enantiomers or racemates. Compared with achiral drugs, they have significant advantages in safety and efficacy with high stereoselectivity. Of these drugs, chirality not only exerts influence on the solubility and pharmacokinetic characteristics but also has specific mechanistic characteristics on their targets. We noted that small molecules with unique chiral properties have emerged as novel components of antitumor drugs approved by the FDA in decade. Since approved, these drugs have been continuously explored for new indications, new mechanisms, and novel combinations. In this mini review, recent research progress of twenty-two FDA-approved chiral small molecular-targeted antitumor drugs from 2011 to 2019 is summarized with highlighting the potential and advantages of their applications. We believe that these updated achievements may provide theoretical foundation and stimulate research interests for optimizing drug efficacy, expanding clinical application, overcoming drug resistance, and advancing safety in future clinical administrations of these chiral targeted drugs.

Store-Operated Calcium Channels as Drug Target in Gastroesophageal Cancers

Gastroesophageal cancers, including tumors occurring in esophagus and stomach, usually have poor prognosis and lack effective chemotherapeutic drugs for treatment. The association between dysregulated store-operated calcium entry (SOCE), a key intracellular Ca2+ signaling pathway and gastroesophageal cancers are emerging. This review summarizes the recent advances in understanding the contribution of SOCE-mediated intracellular Ca2+ signaling to gastroesophageal cancers. It assesses the pathophysiological role of each component in SOCE machinery, such as Orais and STIMs in the cancer cell proliferation, migration, and invasion as well as stemness maintenance. Lastly, it discusses efforts towards development of more specific and potent SOCE inhibitors, which may be a new set of chemotherapeutic drugs appearing at the horizon, to provide either targeted therapy or adjuvant treatment to overcome drug resistance for gastroesophageal cancers.

Delayed Healing of Tooth Extraction Sockets After Vascular Endothelial Growth Factor Inhibition by Bevacizumab

PURPOSE

This study aimed to explore the effect of the chemotherapeutic agent bevacizumab on the extraction socket healing process in New Zealand rabbits.

MATERIALS AND METHODS

The animals received intraperitoneal bevacizumab treatment for 6 consecutive weeks (3 mg/kg per week). The right mandibular first premolar was extracted in the second week of the experiment, and the jaw bone containing the socket tissues was harvested at the end of the treatment period. The healing of the removed socket was analyzed histologically and radiographically using a micro-computed tomography scan.

RESULTS

Quantitative morphometric and histologic assessments of the healing process of the extraction sockets in rabbits showed a marked (P ≤ .05) decrease in the bone volumetric mass after angiogenesis suppression by bevacizumab therapy (n = 5) compared with the control group (n = 5).

CONCLUSIONS

The results of this study indicate the physiological significance of angiogenesis in extraction socket healing. Moreover, this study highlights the risks and precautions that should be considered in clinical practice in patients undergoing targeted chemotherapy.

A phase I study to assess afatinib in combination with carboplatin or with carboplatin plus paclitaxel in patients with advanced solid tumors

PURPOSE

Afatinib, an irreversible ErbB family blocker, has demonstrated preclinical antitumor activity with chemotherapy.

METHODS

As part of a phase I trial in patients with advanced solid tumors (NCT00809133; 3 + 3 dose-escalation design), we determined the maximum tolerated dose (MTD) of afatinib with carboplatin (A/C) or with carboplatin plus paclitaxel (A/C/P). Starting doses: afatinib 20 mg/day, carboplatin AUC6 (A/C) with paclitaxel 175 mg/m2 (A/C/P) (chemotherapy: Day 1 of 21-day cycles). The primary objective was to determine the MTDs; safety, pharmacokinetics and antitumor activity were also evaluated.

RESULTS

Thirty-eight patients received A/C (n = 12) or A/C/P (n = 26). No dose-limiting toxicities (DLTs) were reported with A(20 mg)/C(AUC6). One patient experienced DLT in the A(40 mg)/C(AUC6) cohort (grade 3 acneiform rash); A(40 mg)/C(AUC6) was determined as the recommended phase II dose (RP2D) for A/C. Two patients each had DLTs with A(20 mg/day)/C(AUC6)/P(175 mg/m2): fatigue, infection, diarrhea, small intestine hemorrhage, dehydration, renal impairment, neutropenic sepsis (n = 1), mucositis (n = 1); A(40 mg)/C(AUC5)/P(175 mg/m2): febrile neutropenia (n = 1), mucositis, fatigue (n = 1); and A(30 mg)/C(AUC5)/P(175 mg/m2): stomatitis (n = 1), mucositis (n = 1). No DLT was observed with A(20 mg)/C(AUC5)/P(175 mg/m2), determined as the RP2D for A/C/P. The most frequent drug-related adverse events were (A/C; A/C/P): rash (75%; 73%), fatigue (67%; 69%), and diarrhea (58%; 88%). Drug plasma concentrations were similar between cycles, suggesting no drug-drug interactions. Objective response rates in these heavily pretreated patients were A/C, 3/12 (25%); A/C/P, 5/26 (19%).

CONCLUSIONS

Afatinib 40 mg/day (approved monotherapy dose) with carboplatin AUC6, and afatinib 20 mg/day with carboplatin AUC5 and paclitaxel 175 mg/m2 demonstrated manageable safety and antitumor activity. Afatinib > 20 mg/day in the triple combination was not well tolerated.

Targeting Orai1-mediated store-operated calcium entry by RP4010 for anti-tumor activity in esophagus squamous cell carcinoma

Esophageal cancer (EC) is the 6th leading cause of cancer mortality worldwide with poor prognosis, hence more effective chemotherapeutic drugs for this deadly disease are urgently needed. We previously reported that high expression of Orai1, a store-operated Ca²⁺entry (SOCE) channel, was associated with poor survival rate in EC patients and Orai1-mediated intracellular Ca²⁺ oscillations regulated cancer cell proliferation. Previous studies suggested that Orai1-mediated SOCE is a promising target for EC chemotherapy. Here, we evaluated the anti-cancer effect of a novel SOCE inhibitor, RP4010, in cultured EC cells and xenograft models. Compared to other previously reported SOCE channel inhibitors, RP4010 is more potent in blocking SOCE and inhibiting cell proliferation in EC and other cancer cells. Treatment with RP4010 resulted in reduction of intracellular Ca²⁺ oscillations, caused cell cycle arrest at G0/G1 phase in vitro, decreased nuclear translocation of nuclear factor kappa B (NF-κB) in vivo and in vitro, and inhibited tumor growth in vivo. Taken together, data demonstrated the therapeutic potential of RP4010 in EC patients via inhibition of SOCE-mediated intracellular Ca²⁺ signaling.