A phase II study of sunitinib on a continuous dosing schedule in patients (pts) with relapsed or refractory urothelial carcinoma (UC)

5072

Background: Suntinib has demonstrated activity in the second-line setting for pts with advanced UC when administered on a 4 week on/2 week off schedule. This study was designed to evaluate an alternative 37.5 mg/day continuous dosing schedule for sunitinib in the same setting. Methods: The primary objectives of this single institution phase II study of sunitinib in pts with UC who have failed prior chemotherapy were: 1) to determine the response rate (by RECIST); and 2) to evaluate toxicity. Secondary endpoints include: 1) correlation of response and toxicity with HIF and mTOR pathway marker expression; and 2) phamacokinetics. Pts may not have received >4 prior cytotoxic agents. Pts received sunitinib 37.5 mg/day continuous dosing.. Response was assessed after each of the initial 4 cycles and every other cycle thereafter. A minimax 2-stage design was used (maximal 32 pts). Results: 31 pts (21 M, 10 F) with a median age of 68 yrs and median KPS of 90 were enrolled between 10/15/07 and 12/18/08. Primary sites included bladder (28), and renal pelvis (3). Prior therapy included 1 pt with 1 drug, 19 pts with 2, 7 with 3 and 4 with 4. 25 pts had visceral metastases and 6 pts had lymph node only metastases. 25 pts were evaluable for response after completing at least 1 cycle. One pt achieved PR, 12 pts had SD, 12 had PD, 2 are too early to assess for response, and 4 patients did not complete cycle 1 (2 related to toxicity, and 2 related to non-treatment-related deaths). Radiographic regression was seen in liver, lung, soft tissue and lymph nodes. With a median follow up of 4 months, median progression free survival was 2 months (95% CI, 1 - 4 months) and median overall survival was 7 months (95% CI, 4 months - not achieved). Clinically significant toxicity (Grade 3/4) included: abdominal pain (1), anorexia (1), diarrhea (1), fatigue (4), hand and foot syndrome (2), hemorrhage (2), hypertension (2), mucositis (2), thrombosis (2), and emesis (1). Conclusions: Sunitinib has modest activity when administered on a 37.5 mg continuous dosing schedule to patients with relapsed or refractory UC with a similar toxicity profile to the 50 mg in the 4 /2 schedule. Upcoming trials will evaluate sunitinib in combination with standard chemotherapy in pts with UC.

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Extended pelvic resections for recurrent uterine and cervical cancer: out-of-the-box surgery

Patients with recurrent uterine and cervical cancer have poor prognoses. The objective of this study was to analyze the outcomes of patients with recurrent uterine and cervical cancer who had undergone attempted curative resection of pelvic bone, sidewall muscle, major blood vessels, and/or nerves. We reviewed the records of all 14 patients with recurrent uterine and cervical cancer who had extended pelvic resections at our institution between June 2000 and November 2006. Primary sites of disease were the uterus (11 patients) and cervix (3 patients). Tumor histology was as follows: adenocarcinoma, seven; squamous cell carcinoma, three; leiomyosarcoma, three; and adenosarcoma, one. Previous treatment included hysterectomy, 11; pelvic radiation, 9; chemotherapy, 9; and total pelvic exenteration, 2. Extended pelvic resections included removal of pelvic sidewall muscle, five; bone, five; common and/or external iliac vessel, five; femoral nerve, two; lumbosacral nerve root, one; and obturator nerve, one. Other procedures included total pelvic exenteration, three; posterior exenteration, two; and anterior exenteration, one. Complete resection with negative margins was obtained in 11 (78%) of 14 patients. Seven patients (50%) received high-dose rate intraoperative radiation therapy. Reconstructive procedures included continent or incontinent urinary diversion, four; femoral-femoral arterial bypass, two; myocutaneous flap, two; and urinary ileal interposition, one. Median total operating time was 628 min (range, 345-935 min) and median estimated blood loss was 900 mL (range, 300-16,000 mL). Seven patients (50%) had one or more major complication(s), including pelvic abscess, three; colonic fistula, two; massive intraoperative hemorrhage, one; postoperative bladder perforation, one; thrombosed femoral-femoral graft, one; and disruption of appendicocutaneous urinary anastomosis, one. At a median follow-up of 26 months (range, 5-84 months), ten patients (71%) are alive and four patients (29%) have died of disease at 8, 13, 33, and 42 months postoperatively.

Phase II study of sunitinib in patients (pts) with relapsed or refractory urothelial carcinoma (UC)

5080

Background: Second-line chemotherapy has limited activity in advanced UC. Pre-clinical evidence demonstrates an important role for angiogenesis in UC biology, thus supporting this study of the novel VEGF targeted agent, sunitinib, in pts with UC. Methods: The primary objectives of this single institution phase II trial of sunitinib in pts with UC who have failed prior chemotherapy are: 1) to determine the response rate (RECIST); and 2) to evaluate toxicity. Prior therapy is restricted to = 4 chemotherapy drugs. Pts receive sunitinib 50 mg orally daily for 4 weeks followed by 2 weeks off (one cycle). Response is assessed after each of the initial 4 cycles and every other cycle thereafter. The Simon 2-stage design requires = 2 responses in the first 21 pts to proceed to maximal accrual of 41 evaluable pts. Results: 21 pts (19 male, 2 female) with median age of 64 yrs (39–76) and median KPS of 80 (70–90) were enrolled between 9/15/06 and 1/4/07. Primary tumor sites include bladder (14 pts), ureter/renal pelvis (6 pts) and urethra (1). Prior therapy included 10 pts with 2 drugs, 9 with 3 and 2 with 4. 14 pts have metastatic visceral disease [lung (11), liver (8) and bone (1)], and 7 pts have only lymph node metastases. To date, 15 pts are evaluable for radiographic response after completing at least one cycle of therapy; 6 pts are too early for response assessment. One pt experienced a treatment-related death. Responses include: 1 PR seen after cycle 1 and confirmed after cycle 2, 8 with SD (range -29% to +16% change compared to baseline) and 6 with POD. Radiographic regression has been observed in liver, lung, soft tissue and lymph node metastases. Clinically significant toxicity (Grade 3/4) includes: hematuria (n= 1 pt, 2 events in a bladder primary), mucositis (2 pts), thrombocytopenia (2 pts), infection (1), stomatitis (1), fatigue (1), rash (1), diarrhea (1), and abdominal pain (1). Conclusions: Sunitinib has clinical activity in pts with advanced UC. Accrual is ongoing to define further the level of activity, the duration of response, and the time to progression.

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Phase I study of pemetrexed (P) plus gemcitabine (G) in advanced solid tumors (ST)

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Background: P is active in multiple ST types, and preclinical data support P synergy with G. Methods: Eligible advanced ST patients (pts) with no prior P or G, no prior radiotherapy (RT) to ≡ 25% of the marrow, Karnofsky Performance Status ≡ 70%, and adequate organ function enrolled in cohorts (C) of 3, expanding to 6 if dose-limiting toxicity (DLT) occurred. P was given at 300 (C1), 400 (C2), 500 (C3) or 600 (C4) mg/m2 followed by G at 1500 mg/m2 q 14 days (d) without granulocyte-colony stimulating factor. Vitamin B12 and folate supplementation were given. Response was assessed by RECIST Results: 29 pts (median number prior regimens 2, range 1–5; 66% with prior RT) enrolled and are evaluable for safety; 23 are evaluable for response. There were no DLTs in C1. One pt in C2 was replaced after 1 cycle for progression of disease (PD). Among the next 6 pts, 2 had DLTs (1 G3 thrombocytopenia [TP] treatment delay; 1 neutropenic fever [NF]). C2-R (C2, Revised) re-opened after amendment permitting ≡ 2 prior cytotoxic regimens, no history of brain metastases/brain RT. C2-R enrolled 8 pts with 1 DLT (G3 TP with treatment delay) and 2 pts replaced (1 early PD, 1 no documented duration of neutropenia [NP]). C3 had 0/3 pts with DLT. C4 had 2/3 pts with DLTs (1 G4 hyponatremia; 1 herpes zoster-related treatment delay). C3 has been expanded to 5 of 6 planned patients, one with DLT (NF, G4 TP). Toxicities per cycle (n= 189 cycles, 29 patients): include NP-G3 (23%), G4 (14%); TP-G3 (2%); WBC-G3 (30%), G4 (4%); lymphopenia-G3 (11%), Hgb-G3 (4%); G3-NF (1%). 3/23 (13%) had objective partial responses (2 head and neck squamous cell cancer, HNSCC; 1 nasopharyngeal cancer, NPC), 4 stable disease (SD), 16 PD. (1 pt, no measurable disease at baseline; 5 pts, too early for response assesment). Conclusions: G + P is well-tolerated, and yields objective responses in HNSCC and NPC. C3 (P 500 mg/m2 + G 1500 mg/m2 q 14 d) was the phase II recommended dose in another phase I study of this regimen (Melemed ASCO 2005). Our final results will be available for ASCO 2007.

No significant financial relationships to disclose.

A phase I study of pemetrexed (P) plus gemcitabine (G) in relapsed ovarian cancer (OC): Dosing results and evidence of activity

5083

Background: High expression of folate receptors on ovarian cancer cells may provide excellent targets for P. Preclinical data support synergism with G. Optimal doses of q 14 day P+G with vitamin support in pre-treated OC pts are not known. We sought to determine the maximally tolerated doses (MTD) and to assess for toxicity and activity in relapsed OC. Methods: Pts with relapsed OC, no prior P or G, KPS ≥ 70, and adequate organ function were eligible. Pts were enrolled in cohorts of 3, expanding to 6 if dose-limiting toxicity (DLT) was observed during the first 4 cycles. Pts received P at 300 (cohort 1) or 400 (cohort 2) or 500 (cohort 3) or 600 (cohort 4) mg/m2 followed by G 1500 mg/m2 q 14 d without GCSF. B12 and folic acid were given 1 week prior and continued throughout. DLT was defined as grade (gr) 4 neutropenia (ANC) lasting >7d or neutropenic fever (NF); gr 4 thrombocytopenia or gr 3 with bleeding; ≥gr 3 nonhematologic toxicity, except ALT, AST, alopecia, fatigue; treatment delay ≥1 week due to any unresolved toxicity. Response assessed by RECIST. Results: 16 pts (median age 55, range 43–75; median number prior cytotoxic regimens 2, range 1–4) have enrolled in 4 cohorts. 15 are evaluable for response (1 treated after resection of recurrence); 13 of these15 had a platinum-free interval <6 months. 1 pt in cohort 1 had global deterioration during cycle 1 and was replaced, with best response counted as progressive disease (PD). 1 pt in cohort 3 had dose delay ≥1 week, meeting DLT criteria. Cohort 3 was expanded to 6 pts with no further DLT. 3 pts enrolled in cohort 4 with no DLTs observed. Toxicities per cycle (n = 108): gr 3 ANC 31%; gr 4 ANC 27%; gr 3 dehydration 0.9%; gr 3 platelets 0.9%; 0 pts had NF. Median # cycles/pt was 6, range 1–16, median cycle length 14 d. Objective response was observed in 27% (4/15 pts: 4 PR; 7 SD; 4 PD). All 4 responses were among pts with platinum resistant disease. >50% decrease in CA125 for more than two measurements was observed in 9/15 (60%) pts with evaluable CA125s. Median time to progression is 15 wks (95% confidence interval 10–32 wks). Conclusions: MTD is not yet reached. P 500 mg/m2 + G 1500 mg/m2 with vitamin supplementation is safe in pts with previously treated OC. 27% of patients with platinum-resistant disease had objective responses.

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