A phase I study of nelfinavir, an FDA approved HIV protease inhibitor, in adults with refractory solid tumors

2583

Background: Preclinical studies show that HIV protease inhibitors such as nelfinavir (N) have dose- dependent, pleiotropic anti-cancer activities. However, the maximum tolerated dose (MTD) of N has not been established in humans. Methods: Pts were treated on a modified Fibonacci dose-escalation scheme with a twice daily oral dose of N starting at the FDA approved dose of 1250 mg bid on a 21-day cycle. Patients with refractory solid tumors, ECOG PS < 2, and adequate organ function were eligible. Therapy continued until MTD or disease progression. PBMCs as well as optional tumor biopsies were collected for Akt inhibition and expression of markers of ER stress (ERS). Results: 14 patients have been enrolled. Of the 11 evaluable for toxicity, there were 10 men, 10 Caucasians, and 1 African American (median age 63 years (range 24 - 77)). Tumor types included NSCLC (3), SCLC (2), thyroid (3), pancreatic (1), colorectal (1), and renal cell (1). Median number of prior systemic therapies was 2 (range, 1 - 6). There have been no grade 4 or 5 toxicities. We observed 12 grade 3 toxicities that were asymptomatic laboratory abnormalities. The most prevalent toxicities were ALT transaminitis (5 events in 8 subjects in dose level ((DL) 2, 3, 4), AST transaminitis (4 events in 8 subjects in DL 2, 4), diarrhea (8 events in 5 subjects in DL 2, 3, 4), and hyperglycemia (5 events in 5 subjects in DL 1, 2, 3). Enrollment continues at DL 4 (3125 mg twice daily). There have been no responses. Two subjects with lung cancer had stable disease for 9 weeks. Pharmacokinetic data revealed median Cmax of 2,461.5 ng/ml (DL1), 11,809 ng/ml (DL2), 11,576 ng/ml (DL3), and 11,986 ng/ml (DL4), occurring 4 hours after an oral dose. There was no relationship between the drug levels and albumin levels. Akt inhibition and increased expression of markers of ERS and apoptosis have been observed in PBMCs from week 1 in the majority of patients at every dose level, but there was no correlation with clinical response. Conclusions: N appears to be well tolerated in subjects with advanced solid tumors at 2.5 times the FDA approved dose. AUC data suggest that there may be only minimal increases in plasma drug concentrations with doses above 1875 mg twice daily.

No significant financial relationships to disclose.

Analysis of factors influencing outcome in patients with in transit malignant melanoma (MM) undergoing isolated limb perfusion (ILP) using standardized operative parameters with melphalan and biological agents

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Background: In transit disease afflicts about 10% of MM patients and no single systemic or regional treatment has been widely accepted as most effective or appropriate. Previously, the impact of ILP on the natural history of MM patients has been difficult to gauge. We report long-term outcomes in MM patients undergoing hyperthermic ILP in an era of increasingly accurate staging, uniform operative and treatment conditions, and regular follow-up. Methods: Between 5/1992 to 2/2005, 90 patients (median age: 57 y [range: 24–84]; F: 49, M: 41) with Stage IIIA or IIIAB MM underwent a 90 min hyperthermic (mean calf T: 39.3° C) ILP (melphalan: 10–13 mg/L limb volume, TNF: 3–6 mg [n=44], or IFN: 200 μg [n=38]) using uniform operative technique including intra-operative leak monitoring. There was 1 operative mortality (1/91, 1.1%). Patients were prospectively followed for response, in-field progression free (PFS), and overall survival (OS). Parameters associated with in-field PFS and OS were analyzed by the Kaplan-Meier method with log rank tests, as well as by Cox proportional hazards models. Results: There were 61 complete responses (68%) and 23 partial responses (26%). At a median follow-up of 47 months, median in-field PFS was 12.4 months, and median OS was 47.4 months; 5 and 10-year actuarial OS were 43 and 34%, respectively. Female gender and low tumor burden (< 20 tumors) were associated with prolonged in-field PFS (M:F hazard ratio (HR): 2.07, CI:1.27–3.38; 21+ vs. ≤20 tumors HR: 2.29, CI: 1.21- 4.34; p<0.011 for both) in a Cox model, whereas TNF, IFN, perfusion pressure, and tumor stage were not. Female gender was associated with improved OS (p=0.027, M:F HR=1.82, 95% CI 1.07–3.09) and Stage IIIA marginally so, in univariate analysis, (p=0.065). Conclusions: ILP for MM patients is associated with noteworthy in-field PFS and prolonged OS. Neither use of TNF nor tumor stage were significantly associated with in-field PFS in Cox models, while female gender was associated with better outcomes. In appropriately selected patients using standardized technique, ILP has clinical benefit in this setting.

No significant financial relationships to disclose.

99mTc-human serum albumin: an effective radiotracer for identifying sentinel lymph nodes in melanoma

Sentinel lymph node (SLN) biopsy has emerged as a novel approach for identifying patients with melanoma and regional nodal micrometastasis who may benefit from full nodal basin resection. To identify the pattern of tumor lymphatic drainage and the SLN, lymphoscintigraphy has been performed using primarily 99mTc-sulfur colloid (SC). In this study, we compare the efficacy of SLN biopsy using 99mTc-human serum albumin (HSA) with SLN biopsy after SC-based lymphoscintigraphy.

METHODS

One hundred and six patients with localized cutaneous melanoma were studied. Lymphoscintigraphy was performed after intradermal injection of HSA in 85 patients and SC in 21 patients. Four patients underwent lymphoscintigraphy twice, once with SC and once with HSA. Dynamic images were acquired for up to 1 h, followed by high-count images of the SLN in various projections so that the most likely site was marked on the skin for biopsy. Intraoperatively, blue dye was injected around the primary site. Twenty-four patients underwent SLN dissection directed by preoperative lymphoscintigraphy and vital blue dye mapping; in the remaining 80 patients, a gamma probe was added intraoperatively to the localization procedure. Two patients underwent mapping with gamma probe alone.

RESULTS

Draining lymphatic basins and nodes were identified by lymphoscintigraphy in all patients. The SLN was identified in 95% of patients when both blue dye and intraoperative gamma probe were used. When 99mTc-HSA was used for imaging, 98% of the SLNs ultimately identified were radiolabeled, and 82% were both hot and blue. Of the SLN recovered with SC, all the nodes were radiolabeled; however, there was only 58% hot and blue concordance. Greater numbers of SLNs were removed in the SC group (median 2.0 versus 1.0, P = 0.02); however, the incidence of micrometastasis was statistically similar in both HSA and SC cohorts. In the 4 patients examined with both tracers, SLN mapping was similar.

CONCLUSION

Although SC has been the radiotracer of choice for SLN mapping in melanoma, HSA appears to be a suitable alternative, with identical success rates. In fact, the higher concordance between hot and blue nodes using HSA suggests superiority of this tracer for this purpose.

Immunohistochemistry with pancytokeratins improves the sensitivity of sentinel lymph node biopsy in patients with breast carcinoma

BACKGROUND

Sentinel lymph node (SLN) biopsy is being investigated as a staging procedure for breast carcinoma. The authors evaluated whether immunohistochemical (IHC) analysis improves the sensitivity of this procedure.

METHODS

Forty-four women with breast carcinoma were recruited for SLN biopsy. Preoperative lymphoscintigraphy was followed by intraoperative localization using a handheld gamma probe and blue dye. After SLN identification, an immediate complete axillary lymph node dissection was performed in all patients. All lymph nodes were subjected to routine histology (hematoxylin and eosin [H&E]) and IHC using antibody to cytokeratins.

RESULTS

The SLN was identified in 41 of 43 patients (95%). Successful SLN identification was independent of biopsy technique (open surgical [95%] vs. fine-needle aspiration/core needle biopsy [96%]). Twelve of 41 patients (29%) had evidence of lymph node metastasis in the SLN by routine histology. Of the twenty-nine patients with H&E negative SLN, 3 were found to have metastasis by IHC for a conversion rate of 10%. Fifteen of 41 patients (37%) had evidence of metastasis in SLN. All 26 patients with H&E and IHC negative SLN had negative nonsentinel lymph nodes by routine histology and IHC (100% negative predictive value). All patients with tumors < 2 cm and micrometastasis to the SLN had no additional lymph node disease, in contrast to patients with lesions > 2 cm or patients with macrometastasis to the SLN (P = 0.007).

CONCLUSIONS

These results confirm that SLN biopsy is extremely accurate for patients with breast carcinoma, even after open surgical biopsy. IHC analysis or serial sectioning of SLN improves the sensitivity of this staging technique.