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Embaby A, Heinhuis KM, IJzerman NS, Koenen AM, van der Kleij S, Hofland I, van Boven H, Sanders J, van der Graaf WTA, Haas RL, Huitema ADR, van Houdt WJ, Steeghs N. Propranolol monotherapy in angiosarcoma - A window-of-opportunity study (PropAngio). Eur J Cancer 2024; 202:113974. [PMID: 38452721 DOI: 10.1016/j.ejca.2024.113974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/11/2024] [Accepted: 02/19/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Angiosarcoma is a rare and aggressive cancer of the endothelial cells. Propranolol, a non-selective β-blocker, was able to initiate apoptosis in angiosarcoma cell lines and its anti-tumor activity has been described in several case reports. The aim of this trial was to prospectively evaluate the anti-tumor activity of propranolol monotherapy in patients with angiosarcoma before proceeding to standard of care treatment. METHODS Propranolol was dosed 80 mg to 240 mg/day for 3 to 6 weeks according to a dose titration schedule. The primary endpoint was clinical response (response according to RECIST 1.1 or stable disease with improvement of cutaneous lesions) in at least three patients. Exploratory objectives included histologic response (>30% decrease in Ki-67), FDG PET response, and β-receptor expression levels. RESULTS Fourteen patients were enrolled. The median duration of treatment was 26 days (range 21-42 days). The median highest propranolol dose was 160 mg/day (range 80 - 240 mg). Two patients showed clinical response (14%, 95% CI 3-100%). One of these patients showed a partial metabolic response on PET-CT. None of the tumors showed histologic response. The most common adverse event was grade 1/2 bradycardia (86%). There were no grade ≥ 3 adverse events. ADRB2 was overexpressed in 16 out of 18 tumors, in both responders and non-responders. None of the tumors showed ADRB1 overexpression. CONCLUSIONS This window-of-opportunity trial did not show clinical efficacy of propranolol monotherapy. However, two out of 14 patients did show clinical benefit. ADRB1/2 expression did not correlate with clinical response.
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Affiliation(s)
- Alaa Embaby
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands; Department of Clinical Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands.
| | - Kimberley M Heinhuis
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands; Department of Clinical Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Nikki S IJzerman
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands; Department of Clinical Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Anne Miek Koenen
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Stephanie van der Kleij
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Ingrid Hofland
- Core Facility Molecular Pathology & Biobanking, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Hester van Boven
- Department of Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Joyce Sanders
- Department of Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Winette T A van der Graaf
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Rick L Haas
- Department of Radiotherapy, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands; Department of Pharmacology, Princess Màxima Center for Pediatric Oncology, Utrecht, Netherlands; Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Winan J van Houdt
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands
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van der Burg SJC, van de Wal D, Roets E, Steeghs N, van Sandick JW, Kerst M, van Coevorden F, Hartemink KJ, Veenhof XAAFA, Koenen AM, Ijzerman N, van der Graaf WTA, Schrage YM, van Houdt WJ. Neoadjuvant Imatinib in Locally Advanced Gastrointestinal Stromal Tumors (GISTs) is Effective and Safe: Results from a Prospective Single-Center Study with 108 Patients. Ann Surg Oncol 2023; 30:8660-8668. [PMID: 37814179 DOI: 10.1245/s10434-023-14346-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/06/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Neoadjuvant imatinib is considered for gastrointestinal stromal tumors (GISTs) when decreased tumor size provides less extensive surgery and higher R0 resection rates. This study evaluates the effectivity and safety of neoadjuvant imatinib for large or locally advanced GIST. PATIENTS AND METHODS From the prospective database of the Dutch GIST Consortium, all patients who underwent surgery after neoadjuvant imatinib at our center between 2009 and 2022 were selected. Independent and blinded assessment of surgical strategy was performed by two surgeons, based on anonymized computed tomography (CT) scans before and after neoadjuvant imatinib. RESULTS Of 113 patients that received neoadjuvant imatinib, 108 (95%) [mean age 61.6, standard deviation (SD) 11.5, 54% male] underwent a GIST resection. Of all GISTs, 67% was localized in the stomach and 25% in the duodenum or small intestine. In 74% of the patients with GIST, a KIT exon 11 mutation was found. Decreased tumor size was seen in 95 (88%) patients. Having a KIT exon 11 mutation [odds ratio (OR) 5.64, 95% confidence interval (CI) 1.67-19.1, p < 0.01] or not having a mutation (OR 0.19, 95% CI 0.04-0.89, p = 0.04) were positive and negative predictive values for partial response, respectively. In 55 (51%) patients, there was deescalation of surgical strategy after neoadjuvant imatinib. Surgical complications were documented in 16 (15%) patients (n = 8, grade II; n = 5, grade IIIa; n = 3, grade IIIb) and R0 resection was accomplished in 95 (89%) patients. The 5-year disease-free and overall survival were 80% and 91%, respectively. CONCLUSION This study shows that neoadjuvant imatinib is effective and safe for patients with large or locally advanced GIST.
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Affiliation(s)
- Stijn J C van der Burg
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
| | - Deborah van de Wal
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
| | - Evelyne Roets
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
- Dutch Sarcoma Group, Dutch GIST Consortium, Utrecht, The Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
- Dutch Sarcoma Group, Dutch GIST Consortium, Utrecht, The Netherlands
| | - Johanna W van Sandick
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
| | - Martijn Kerst
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
| | - Frits van Coevorden
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
| | - Koen J Hartemink
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
| | - Xander A A F A Veenhof
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
| | - Anne Miek Koenen
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
| | - Nikki Ijzerman
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
| | - Winette T A van der Graaf
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
| | - Yvonne M Schrage
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands
- Dutch Sarcoma Group, Dutch GIST Consortium, Utrecht, The Netherlands
| | - Winan J van Houdt
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands.
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van Meekeren M, Bovee JVMG, van Coevorden F, van Houdt W, Schrage Y, Koenen AM, Miah AB, Zaidi S, Hayes AJ, Thway K, Krol S, Fiocco M, Gelderblom H, Steeghs N, Haas RL. A phase II study on the neo-adjuvant combination of pazopanib and radiotherapy in patients with high-risk, localized soft tissue sarcoma. Acta Oncol 2021; 60:1557-1564. [PMID: 34554030 DOI: 10.1080/0284186x.2021.1971294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE A prior phase I study showed that the neo-adjuvant combination of pazopanib and radiotherapy was well tolerated, and induced promising pathological responses in soft-tissue sarcoma patients. Results of the subsequent prospective, multicenter phase II, PASART-2 trial are presented here, further investigating the efficacy and safety of this combination. PATIENTS AND METHODS Patients with high-risk, localized soft-tissue sarcoma received neo-adjuvant radiotherapy, 50 Gy in 25 fractions (PASART-2A) or with a subsequent dose de-escalation to 36 Gy in 18 fractions (PASART-2B). This was combined with 800 mg once daily pazopanib, which started one week before radiotherapy and finished simultaneously. After an interval of 4-8 weeks, surgical resection was performed. The primary endpoint was the rate of pathological complete responses (pCR), defined as ≤5% viable cells. RESULTS 25 patients were registered in the study, 21 in PASART-2A and 4 in PASART-2B. After central pathology review, the combination treatment led to a pCR in 5 patients (20%). 17 patients (68%) experienced grade 3+ toxicities during neo-adjuvant treatment, of which the most common were alanine aminotransferase (ALT) elevation, aspartate aminotransferase (AST) elevation, and hypertension, all asymptomatic. Grade 3+ acute post-operative toxicities occurred in 5 patients (20%), of which the most common was wound infection. All patients completed the full radiotherapy regimen and underwent surgery. Pazopanib was discontinued before completion in 9 patients (36%), due to elevated ALT and/or AST, and shortly interrupted in 2 patients (8%), due to hypertension. CONCLUSION Apart from asymptomatic hepatotoxicity, the study regimen was well tolerated. Although the pre-specified efficacy endpoint (30% pCR) was not met, a more than doubling of historical pCR rates after neo-adjuvant radiotherapy alone was observed, which warrants further investigation.
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Affiliation(s)
- Milan van Meekeren
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Frits van Coevorden
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Winan van Houdt
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Yvonne Schrage
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Anne Miek Koenen
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Aisha B. Miah
- Department of Clinical Oncology, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom
| | - Shane Zaidi
- Department of Clinical Oncology, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom
| | - Andrew J. Hayes
- Department of Surgery, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom
| | - Khin Thway
- Department of Pathology, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom
| | - Stijn Krol
- Department of Radiotherapy, Leiden University Medical Center, Leiden, the Netherlands
| | - Marta Fiocco
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Rick L. Haas
- Department of Radiotherapy, Leiden University Medical Center, Leiden, the Netherlands
- Department of Radiotherapy, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Heinhuis KM, IJzerman NS, Koenen AM, van der Graaf WTA, Haas RL, Beijnen JH, Huitema ADR, van Houdt WJ, Steeghs N. PropAngio study protocol: a neoadjuvant trial on the efficacy of propranolol monotherapy in cutaneous angiosarcoma-a proof of principle study. BMJ Open 2020; 10:e039449. [PMID: 32912994 PMCID: PMC7485254 DOI: 10.1136/bmjopen-2020-039449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Angiosarcoma is a rare and aggressive malignancy with a high metastatic potential and recurrence rate. Despite optimal treatment with surgery, with or without radiation, the prognosis remains poor and, therefore, new treatment strategies are warranted. Recently, propranolol has effectively been repurposed for the treatment of infantile haemangioma. Propranolol is a β3-sparing antagonist of the β-adrenergic receptor. In infantile haemangioma, the β1, β2 and β3 receptors are highly expressed. Angiosarcoma has several similarities with haemangioma, including its high β-adrenergic receptor expression and the supposedly important role of vascular endothelial growth factor in malignant growth. As a result, propranolol has been administered small scale in individual angiosarcoma cases with promising results. The precise effect of propranolol, however, is not yet established. METHODS AND ANALYSIS The goal of this neoadjuvant window of opportunity study is to prospectively evaluate the activity of propranolol monotherapy in patients with cutaneous angiosarcoma. The neoadjuvant setting provides a good opportunity to rapidly evaluate both the clinical response and histological response, without a significant delay in standard anticancer treatment. Fourteen patients with primary, recurrent or metastatic cutaneous angiosarcoma will be included. Propranolol will be administered orally in an escalating dose during 3-6 weeks, before the initiation of standard treatment. The primary endpoint is clinical response according to Response Evaluation Criteria in Solid Tumours, as measured on consecutive coloured photographs or CT/MRI. The histological response will be determined as secondary endpoint, comparing the difference in proliferation index before and after propranolol by measuring the change in immunohistochemistry staining of Ki-67. The study will be considered positive when at least three patients have a response to propranolol. ETHICS AND DISSEMINATION Ethical approval was obtained from the Medical Ethical Committee of the Netherlands Cancer Institute. Independent of the outcome, results of this study will be shared and submitted for publication in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER NL8118; registry through the Netherlands Trial Register.
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Affiliation(s)
- Kimberley M Heinhuis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nikki S IJzerman
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anne Miek Koenen
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Winette T A van der Graaf
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rick L Haas
- Department of Radiotherapy, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Winan J van Houdt
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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5
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IJzerman NS, Groenland SL, Koenen AM, Kerst M, van der Graaf WTA, Rosing H, Beijnen JH, Huitema ADR, Steeghs N. Therapeutic drug monitoring of imatinib in patients with gastrointestinal stromal tumours - Results from daily clinical practice. Eur J Cancer 2020; 136:140-148. [PMID: 32688207 DOI: 10.1016/j.ejca.2020.05.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 11/20/2022]
Abstract
AIM Higher imatinib exposure is correlated with longer time to progression, while the variability in exposure is high. This provides a strong rationale for therapeutic drug monitoring, which has therefore been implemented in routine clinical practice in our institute. The aim of this study is to evaluate whether pharmacokinetically (PK)-guided dose increases are feasible in daily clinical practice and result in an improved exposure (Cmin≥1100 ng/mL) and longer progression-free survival (PFS). METHODS This retrospective study included all patients with a gastrointestinal stromal tumour (GIST) in the Netherlands Cancer Institute who started imatinib treatment at a dose of 400 mg and of whom PK plasma samples were available. Of these patients, minimum plasma concentrations (Cmin) of imatinib, frequency and successfulness of PK-guided dose increases and PFS in the palliative treatment setting were analysed. RESULTS In total, 169 consecutive patients were included, of whom 1402 PK samples were collected. In 126 patients (75%), Cmin was below the efficacy threshold of 1100 ng/mL. In 78 of these patients (62%), a PK-guided dose increase was performed, which was successful in 49 patients (63%). PFS was similar in patients with and without imatinib dose increase. However, due to the small number of patients with progressive disease, no definite conclusions on the effect on PFS could yet be drawn. CONCLUSION This is the largest cohort evaluating PK-guided dose increases of imatinib in patients with GIST in routine clinical practice and demonstrating its feasibility. PK-guided dose increases should be applied to optimise exposure in the significant subset of patients with a low Cmin.
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Affiliation(s)
- Nikki S IJzerman
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Erasmus MC - Cancer Institute, Department of Medical Oncology, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Anne Miek Koenen
- Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Martijn Kerst
- Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Winette T A van der Graaf
- Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Department of Pharmaceutical Sciences, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, the Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Department of Clinical Pharmacy, University Medical Center, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, the Netherlands
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
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Rozeman EA, Menzies AM, van Akkooi ACJ, Adhikari C, Bierman C, van de Wiel BA, Scolyer RA, Krijgsman O, Sikorska K, Eriksson H, Broeks A, van Thienen JV, Guminski AD, Acosta AT, Ter Meulen S, Koenen AM, Bosch LJW, Shannon K, Pronk LM, Gonzalez M, Ch'ng S, Grijpink-Ongering LG, Stretch J, Heijmink S, van Tinteren H, Haanen JBAG, Nieweg OE, Klop WMC, Zuur CL, Saw RPM, van Houdt WJ, Peeper DS, Spillane AJ, Hansson J, Schumacher TN, Long GV, Blank CU. Identification of the optimal combination dosing schedule of neoadjuvant ipilimumab plus nivolumab in macroscopic stage III melanoma (OpACIN-neo): a multicentre, phase 2, randomised, controlled trial. Lancet Oncol 2019; 20:948-960. [PMID: 31160251 DOI: 10.1016/s1470-2045(19)30151-2] [Citation(s) in RCA: 298] [Impact Index Per Article: 59.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 03/08/2019] [Accepted: 03/14/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The outcome of patients with macroscopic stage III melanoma is poor. Neoadjuvant treatment with ipilimumab plus nivolumab at the standard dosing schedule induced pathological responses in a high proportion of patients in two small independent early-phase trials, and no patients with a pathological response have relapsed after a median follow up of 32 months. However, toxicity of the standard ipilimumab plus nivolumab dosing schedule was high, preventing its broader clinical use. The aim of the OpACIN-neo trial was to identify a dosing schedule of ipilimumab plus nivolumab that is less toxic but equally effective. METHODS OpACIN-neo is a multicentre, open-label, phase 2, randomised, controlled trial. Eligible patients were aged at least 18 years, had a WHO performance status of 0-1, had resectable stage III melanoma involving lymph nodes only, and measurable disease according to the Response Evaluation Criteria in Solid Tumors version 1.1. Patients were enrolled from three medical centres in Australia, Sweden, and the Netherlands, and were randomly assigned (1:1:1), stratified by site, to one of three neoadjuvant dosing schedules: group A, two cycles of ipilimumab 3 mg/kg plus nivolumab 1 mg/kg once every 3 weeks intravenously; group B, two cycles of ipilimumab 1 mg/kg plus nivolumab 3 mg/kg once every 3 weeks intravenously; or group C, two cycles of ipilimumab 3 mg/kg once every 3 weeks directly followed by two cycles of nivolumab 3 mg/kg once every 2 weeks intravenously. The investigators, site staff, and patients were aware of the treatment assignment during the study participation. Pathologists were masked to treatment allocation and all other data. The primary endpoints were the proportion of patients with grade 3-4 immune-related toxicity within the first 12 weeks and the proportion of patients achieving a radiological objective response and pathological response at 6 weeks. Analyses were done in all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT02977052, and is ongoing with an additional extension cohort and to complete survival analysis. FINDINGS Between Nov 24, 2016 and June 28, 2018, 105 patients were screened for eligibility, of whom 89 (85%) eligible patients were enrolled and randomly assigned to one of the three groups. Three patients were excluded after randomisation because they were found to be ineligible, and 86 received at least one dose of study drug; 30 patients in group A, 30 in group B, and 26 in group C (accrual to this group was closed early upon advice of the Data Safety Monitoring Board on June 4, 2018 because of severe adverse events). Within the first 12 weeks, grade 3-4 immune-related adverse events were observed in 12 (40%) of 30 patients in group A, six (20%) of 30 in group B, and 13 (50%) of 26 in group C. The difference in grade 3-4 toxicity between group B and A was -20% (95% CI -46 to 6; p=0·158) and between group C and group A was 10% (-20 to 40; p=0·591). The most common grade 3-4 adverse events were elevated liver enzymes in group A (six [20%)]) and colitis in group C (five [19%]); in group B, none of the grade 3-4 adverse events were seen in more than one patient. One patient (in group A) died 9·5 months after the start of treatment due to the consequences of late-onset immune-related encephalitis, which was possibly treatment-related. 19 (63% [95% CI 44-80]) of 30 patients in group A, 17 (57% [37-75]) of 30 in group B, and nine (35% [17-56]) of 26 in group C achieved a radiological objective response, while pathological responses occurred in 24 (80% [61-92]) patients in group A, 23 (77% [58-90]) in group B, and 17 (65% [44-83]) in group C. INTERPRETATION OpACIN-neo identified a tolerable neoadjuvant dosing schedule (group B: two cycles of ipilimumab 1 mg/kg plus nivolumab 3 mg/kg) that induces a pathological response in a high proportion of patients and might be suitable for broader clinical use. When more mature data confirm these early observations, this schedule should be tested in randomised phase 3 studies versus adjuvant therapies, which are the current standard-of-care systemic therapy for patients with stage III melanoma. FUNDING Bristol-Myers Squibb.
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Affiliation(s)
| | - Alexander M Menzies
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | | | - Chandra Adhikari
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia
| | | | | | - Richard A Scolyer
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | | | - Hanna Eriksson
- Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | | | | | - Alexander D Guminski
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | | | | | | | | | - Kerwin Shannon
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Loes M Pronk
- The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Maria Gonzalez
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia
| | - Sydney Ch'ng
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | - Jonathan Stretch
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Stijn Heijmink
- The Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | - Omgo E Nieweg
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | | | - Robyn P M Saw
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | | | - Andrew J Spillane
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | - Johan Hansson
- Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | | | - Georgina V Long
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia
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Van Der Graaf WT, Vlenterie M, Steeghs N, Desar I, Verheijen RB, Koenen AM, Grootjans W, de Geus-Oei LF, Oyen WJ, Van Erp NP. Early metabolic response as predictor for treatment outcome of pazopanib in patients with metastatic soft tissue sarcomas (the PREDICT study). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.11555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Neeltje Steeghs
- The Netherlands Cancer Institute (NKI), Amsterdam, Netherlands
| | - Ingrid Desar
- Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Anne Miek Koenen
- Antoni van Leeuwenhoek – Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | - Wim J.G. Oyen
- The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Nielka P. Van Erp
- Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
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