Phase II randomized trial of radiation therapy, cetuximab, and pemetrexed with or without bevacizumab in patients with locally advanced head and neck cancer

BACKGROUND

We previously reported the safety of concurrent cetuximab, an antibody against epidermal growth factor receptor (EGFR), pemetrexed, and radiation therapy (RT) in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN). In this non-comparative phase II randomized trial, we evaluated this non-platinum combination with or without bevacizumab, an inhibitor of vascular endothelial growth factor (VEGF).

PATIENTS AND METHODS

Patients with previously untreated stage III-IVB SCCHN were randomized to receive: conventionally fractionated radiation (70 Gy), concurrent cetuximab, and concurrent pemetrexed (arm A); or the identical regimen plus concurrent bevacizumab followed by bevacizumab maintenance for 24 weeks (arm B). The primary end point was 2-year progression-free survival (PFS), with each arm compared with historical control. Exploratory analyses included the relationship of established prognostic factors to PFS and quality of life (QoL).

RESULTS

Seventy-eight patients were randomized: 66 oropharynx (42 HPV-positive, 15 HPV-negative, 9 unknown) and 12 larynx; 38 (49%) had heavy tobacco exposure. Two-year PFS was 79% [90% confidence interval (CI) 0.69-0.92; P < 0.0001] for arm A and 75% (90% CI 0.64-0.88; P < 0.0001) for arm B, both higher than historical control. No differences in PFS were observed for stage, tobacco history, HPV status, or type of center (community versus academic). A significantly increased rate of hemorrhage occurred in arm B. SCCHN-specific QoL declined acutely, with marked improvement but residual symptom burden 1 year post-treatment.

CONCLUSIONS

RT with a concurrent non-platinum regimen of cetuximab and pemetrexed is feasible in academic and community settings, demonstrating expected toxicities and promising efficacy. Adding bevacizumab increased toxicity without apparent improvement in efficacy, countering the hypothesis that dual EGFR-VEGF targeting would overcome radiation resistance, and enhance clinical benefit. Further development of cetuximab, pemetrexed, and RT will require additional prospective study in defined, high-risk populations where treatment intensification is justified.

Serum biomarkers as predictors of clinical outcome after cetuximab-based therapy in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN)

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Background: We correlated a panel of serum cytokines and growth factors with antitumor activity in patients (pts) with locally advanced SCCHN treated with cetuximab-based therapy. We have shown that similar biomarkers may be promising for the early detection of SCCHN (Linkov, Can Epi Biomarkers 2007). Methods: We used multi-analyte biomarker profiling for measurement of multiple serum biomarkers (Luminex Corp., Austin, TX). 39 pts with stage III-IVB SCCHN were treated with cisplatin, docetaxel, and cetuximab (TPE) for 3 cycles followed by radiotherapy, cisplatin, and cetuximab (XPE) and then maintenance cetuximab (Argiris, ASCO 2008, A6002). 31 cytokines and growth factors were measured before and after 3 cycles (9 weeks) of induction TPE. Clinical results were correlated with biomarkers, including 23 pts with PET response. Results: 31 pts had baseline biomarkers and 25 paired samples, pre- and post-TPE. Median follow-up was 22 months. Median age 54 years (21–74); male: 27; stage IV: 29; primary site: oropharynx, 16; larynx, 4; hypopharynx, 3, nasopharynx, 3; oral cavity, 3; and unknown, 2. Eight analytes changed significantly after induction. Adjusting p values for false discovery, the following analytes retain a p <0.05: MCP1c, IP-10, Leptin, IL-5, Eotaxin, IL-6, GCSF, CXCL5. In 23 pts with PET response assessment, low vascular endothelial growth factor (VEGF) levels or low IL-6 levels at baseline may be associated with complete response: 4/5 pts with low baseline VEGF (<20.9 pg/ml) had a complete response by PET vs 1/18 pts with high baseline VEGF. Of 31 pts, 9 have progressed. Among tests of association of the 31 analytes and progression-free survival (PFS), VEGF was the only one with a raw p value <.05 (p = .027), although the adjusted p value was not significant. A decrease in VEGF with treatment had a weak but not statistically significant association with longer PFS. Conclusions: Baseline serum biomarkers and in particular, VEGF and IL-6, were identified as potentially useful predictive markers of cetuximab-based therapy. Due to the small sample size and multiple testing, these biomarkers need to be validated in a larger study in SCCHN specifically powered for biomarker associations.

No significant financial relationships to disclose.

Phase II trial of docetaxel (T), cisplatin (P), and cetuximab (E) followed by concurrent radiation (RT), P, and E in locally advanced head and neck squamous cell carcinoma (HNSCC)

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Background: E is a chimeric IgG1 monoclonal antibody against the external domain of the epidermal growth factor receptor that may enhance the efficacy of RT and chemotherapy. Our goal was to incorporate E in the induction and subsequent chemoradiotherapy of HNSCC. We report our preliminary results with TPE induction. Methods: Patients (pts) had pathologically documented HNSCC stage III/IV or selected stage II (base of tongue, hypopharynx, or nasopharynx), no prior therapy, ECOG PS 0–1, and adequate hematologic, kidney and liver laboratory parameters. Induction consisted of T 75 mg/m2 day 1, P 75 mg/m2 day 1, and E 250 mg/m2 days 1,8, and 15 (after an initial dose of 400 mg/m2 on cycle 1, day 1), repeated every 21 days × 3 cycles. Subsequently, pts received RT 70 Gy (2 Gy/day) with concurrent P 30 mg/m2 and E 250 mg/m2 weekly, followed by maintenance E for 6 months. Prophylactic antibiotics were given on days 5–14 of each TPE cycle. Tumor assessment was performed after induction (primary endpoint) and 8 weeks after RT. Sample size was 39; one-stage design; target overall response rate (ORR): 80%. Results: 21 pts have been enrolled to date: median age 55 (39–74); Male/Female: 18/3; primary site: oropharynx (n=13), larynx (n=5), and other (n=3); stage III/IV: 4/17. In 16 evaluable pts, ORR to TPE was 15/16 (94%), CR: 2, PR 13, SD 1. For the primary site (12 evaluable): CR 6, PR 5, SD 1; for the lymph nodes (14 evaluable): CR 1, PR: 12, SD 1. The pt with SD discontinued E in the first cycle due to recurring infusion reaction. Another patient had a grade (G) 3 infusion reaction on the first E administration and was removed from study. Other serious toxicities during TPE (n=20): grade (G) 3/4 neutropenia (n=4/n=7) without incidence of neutropenic fever, G 3 anemia (n=1), G 3 thrombocytopenia (n=1), G 3/4 hypomagnesemia (n=2/n=1), G 3 rash (n=1), G 3 fatigue (n=4), and G 3 diarrhea (n=1). 1 pt had sudden death due to myocardial infarction (autopsy) after the third cycle of TPE. Subsequent RT plus P and E was feasible. 10 pts completed RT and all remain progression-free. Conclusions: Preliminary results suggest that TPE has predictable and manageable toxicities and high activity in HNSCC. Accrual is ongoing and updated data will be available.

No significant financial relationships to disclose.

Phase II trial of pemetrexed (P) and bevacizumab (B) in patients (pts) with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC): An interim analysis

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Background: P is a multi-targeted antifolate with single-agent activity in recurrent or metastatic HNSCC (RR 26%, Pivot et al. Br J Cancer 2001;85:649–55) and a preferable toxicity profile compared with cisplatin or the taxanes. B is a monoclonal antibody against the vascular endothelial growth factor that has been successfully incorporated in the treatment of other advanced solid tumors. Methods: Eligible pts had pathologically documented HNSCC, ECOG performance status 0–1, measurable disease, no history of bleeding diathesis or hemoptysis, and were not on anticoagulation. Pts had no prior systemic therapy for recurrent or metastatic HNSCC; chemotherapy as part of initial potentially curative therapy, but without P or B, was allowed if completed >6 months earlier. Treatment consisted of P 500 mg/m2 and B 15 mg/Kg, both given intravenously every 21 days, until disease progression or intolerable toxicity. All patients received folic acid, vitamin B12, and corticosteroid prophylaxis. The primary endpoint was the time to progression (TTP) with a sample size of 40 pts (one stage design) with planned interim safety analysis after the first 6 and 12 pts. Results: 14 pts have been enrolled. Median age 64 years (35–84); male/female 13/1; PS 0/1: 7/7; prior chemotherapy: 8; primary site: oropharynx (7), larynx (4), oral cavity (3). Median number of cycles 5 (1–10). With a median follow up of 5.5 months, median TTP was 6 months (95% CI, 4–8). 11 pts were evaluable for response using RECIST. Best response was CR: 2, PR: 3, SD: 6, PD: 0, with ORR 45%. There were no grade 4 toxicities in 14 evaluable pts; 2 pts had grade 3 hemorrhagic events in the first cycle (1 tumor-related and 1 due to gastric ulcer post gastrostomy tube placement), and both discontinued treatment. 3 other pts had grade 1–2 hemorrhagic events. The relationship of these events to treatment was difficult to ascertain. Other grade 3 toxicities were stomatitis, dysphagia, and fatigue (all occurred in 1 pt). Conclusions: Preliminary results show that P plus B is a novel, highly active regimen that may represent a new treatment paradigm in HNSCC. However, bleeding complications were frequent in pts with susceptibility to such events. Study accrual continues.

No significant financial relationships to disclose.

[A comparative multicenter study of the efficacy of single- and double-lumen catheter drainage]

Our study was aimed at comparing the therapeutic efficiency of single and double lumen catheters in the drainage of abdominal fluid collections. We report the results of in vitro and in vivo studies carried out to assess the usefulness of each catheter type based on its therapeutic results. In the in vitro study the aspiration efficacy of the catheters was tested in a simulated cavity. In the in vivo study 188 patients with 206 fluid collections in the abdomen were examined; the patients had been treated percutaneously with single or double lumen catheters, randomly. In each patient we studied drainage efficiency related to aspiration efficacy, the time the catheter rested in the cavity, patient's discomfort and finally the cost of both the device and hospitalization. Some patients underwent surgery for specific reasons, but nevertheless their clinical conditions were absolutely improved thanks to percutaneous drainage. The results of this study yield useful clinical data to choose the most suitable catheter for the percutaneous treatment of abdominal fluid collections. Single lumen catheters work better than double lumen ones, the latter being also more expensive. Hospitalization time is also reduced when single lumen catheters are used.