BACKGROUNDThis phase I/II study was conducted to determine the maximum tolerated dose (MTD), safety, and efficacy of lenalidomide plus sunitinib in metastatic renal cell carcinoma (RCC) patients.PATIENTS AND METHODSPatients with histologically confirmed, metastatic RCC were treated with 10 mg/day lenalidomide plus 37.5 mg/day sunitinib, orally in 21-day cycles. Doses were escalated to determine the MTD in phase I, with additional patients planned at this dose in phase II. Primary end points were MTD and response rate.RESULTSSixteen patients received a median of 2, 3, and 5 cycles in cohort 1 [lenalidomide 10 mg (days 1-21) and sunitinib 37.5 mg (days 1-21)], cohort 2 [lenalidomide 10 mg (days 1-21) and sunitinib 37.5 mg (days 1-14)], and cohort 3 [lenalidomide 15 mg (days 1-21) and sunitinib 37.5 mg (days 1-14)], respectively. Median treatment durations were 41, 63, and 97 days for lenalidomide; and 41, 57, and 97.5 days for sunitinib. The MTD was found to be continuous dosing of lenalidomide 10 mg/day plus sunitinib 37.5 mg/day for 14 of 21 days. Dose-limiting toxicities included neutropenia, leukopenia, thrombocytopenia, asthenia, atrial fibrillation, and increased transaminases. The most frequent grade 3-4 treatment-emergent adverse events were hematologic, including neutropenia and leukopenia. One patient achieved partial response, and seven had stable disease of which three were confirmed at subsequent tumor assessments. B cells and several T-cell subsets were modulated versus baseline.CONCLUSIONThe dose schedules of lenalidomide and sunitinib evaluated in this study were not well tolerated; cumulative toxicity precluded enrollment at the MTD.

ABSTRACT Background Tumor EGFR and KRas mutations are both predictive and prognostic biomarkers in patients with advanced NSCLC. We analyzed the correlation between these biomarkers and treatment outcomes in a phase III trial of 3rd/4th line sorafenib in patients with NSCLC. Methods The global, randomized, placebo-controlled MISSION trial enrolled 703 patients with advanced relapsed/refractory NSCLC of predominantly non-squamous histology. The primary study endpoint was overall survival (OS). EGFR and KRas mutations were analyzed in archival tumor samples and in circulating tumor DNA isolated from plasma. Results Tumor and/or plasma mutation data were available from 347 patients (49%). EGFR and KRas mutations were detected in 89 (26%) and 68 (20%) patients, respectively, and were well balanced between treatment arms. Analysis of the interaction between EGFR mutation status and treatment effect on survival suggested that patients with EGFR mutations (mEGFR) benefitted from sorafenib, while those with wild-type EGFR (wtEGFR) did not (p = 0.023). Median OS was two-fold longer in mEGFR patients receiving sorafenib versus placebo (423 vs 197 days, HR 0.48, p = 0.002). There was no significant difference in OS between patients with wtEGFR receiving sorafenib or placebo (253 vs 256 days, HR 0.92, p = 0.559). An interaction was also seen between EGFR mutation status and the sorafenib effect on PFS (p = 0.015). Patients with mEGFR treated with sorafenib had better outcomes compared to placebo based on Cox regression analysis (HR 0.27, p  Conclusion Post-hoc analyses of efficacy outcomes in MISSION suggest that advanced NSCLC patients with EGFR mutations may derive a survival benefit from receiving 3rd/4th line sorafenib. These results must be interpreted with caution due to the small, non-representative nature of the genetic biomarker subpopulation analyzed in this trial. Further prospective investigation may be warranted. Disclosure T.S.K. Mok: Honoraria: AstraZeneca, Roche, Eli Lilly, Merck Serono, Eisai, BMS, BeiGene, AVEO, Pfizer, Taiho, Boehringer Ingelheim, and GSK Biologicals Speaker: Astrazeneca, Roche, Eli Lilly, Boehringer Ingelheim, and Merck Serono Research funding: Astrazeneca. L. Paz-Ares: Dr. Paz-Ares has received honoraria from Bayer HealthCare Pharmaceuticals, Lilly, Roche and Pfizer. Y. Wu: Dr. Wu has received lecture fees from Roche, AstraZeneca, Eli Lilly, and Pfizer. V. Hirsh: Member of the steering committee for the MISSION trial. C. Lathia: Dr. Lathia is an employee of Bayer HealthCare. T.J. Ong: Dr. Ong is an employee of, and owns shares in, Bayer HealthCare. C. Pena: Dr. Pena is an employee of Bayer HealthCare. All other authors have declared no conflicts of interest.

ABSTRACT Introduction LEN, an antiangiogenic and immunomodulatory agent was active and well tolerated as a single agent and in combination with DP in phase 1/2 trials in CRPC. This phase 3, multicenter, randomized, double-blind, placebo (PBO)-controlled study evaluated the efficacy and safety of LEN versus PBO in combination with DP as first-line treatment for CRPC. Methods Chemotherapy-naive patients with progressive metastatic CRPC were randomized to the LEN + DP arm (oral [p.o.] LEN 25 mg/day on days 1–14 of each 21-day cycle) or the PBO + DP arm (PBO in the same schedule). In both arms, docetaxel was administered intravenously at 75 mg/m2 on day 1 of each cycle, and prednisone was dosed 5 mg p.o. twice daily. Primary endpoint was overall survival (OS) and secondary endpoints were progression-free survival (PFS), objective response rate, and safety. Patient enrollment was completed in Nov 2011 with a total of 1059 patients randomized. The data analysis results were based on the cut-off date of Jan. 13, 2012. Results 533 patients were randomized in the LEN + DP and 526 patients in the PBO + DP arm. The arms were well balanced; mean age was 69 years and ECOG PS scores were 0 in 48.1% and 1 in 47.5% of patients. Median number of cycles administered was 6 and 8 in the LEN + DP and PBO + DP arms, respectively. The most common grade ≥ 3 adverse events in the LEN + DP arm included neutropenia (22%), febrile neutropenia (12%), neutropenic sepsis (3%). Vascular events grade > 3 were reported in 7.4% of patients in the LEN + DP arm versus 4.4% in the PBO + DP arm. No increased mortality due to toxicity was seen. Median OS and PFS was 77 and 45 weeks in the LEN + DP arm, compared to median not reached (p = 0.0017) and 46 weeks (p = 0.0187), in the PBO + DP arm, respectively. Hazard ratio (LEN over PBO) is 1.53 (95% CI = 1.17 to 2.00) for OS and 1.32 (95% CI = 1.05 to 1.66) for PFS. Conclusions The addition of LEN to DP did not improve OS in patients with CRPC and was associated with greater toxicity. Shorter treatment duration, lower dose intensity and earlier treatment discontinuation might have contributed to this lack of benefit. Studies to explain the poorer outcome of the LEN arm are underway. Disclosure D.P. Petrylak: Advisory board: Amgen, Bayer, Pfizer, Ferring, Millenium, Novartis, Dendreon, Johnson and Johnson, GlaxoSmithKline. Corporate sponsored research: Celgene, Dendreon, Sanofi, Pfizer, AstraZeneca, GlaxoSmithKline, Rogesen institute, Boehringer Ingelheim. K. Fizazi: Participation to advisory boards for Sanofi-Aventis and Celgene C.N. Sternberg: Honoraria: Johnson + Johnson, Astellas, Amgen and Sanofi-Aventis Research funding: Cougar J. Bellmunt: Consultancy and adboard contribution for Cellgene and Sanofi (compensated) D. Barton: Celgene employee and stock owner A. Fandi: Celgene employee and stock owner U. Jungnelius: Celgene Corporation: Company employee S. Li: Statistician working at Celgene. I have Celgene stock options as a regular employee. N. Vogelzang: Member of the MAINSAIL steering committee, did not receive direct funds from Celgene for conducting the research as it was conducted thru US Oncology/McKesson. Honoraria from Celgene for lectures. Salary compensation from US Oncology Research All other authors have declared no conflicts of interest.

In a multicentre phase III study of disseminated malignant melanoma performed in Sweden and Norway, 326 patients were randomised to receive treatment with the combination dacarbazine [DTIC] (D) and vindesine (V) with or without the addition of cisplatin (P). D was given intravenously (i.v.) at a dose of 250 mg/m2 days 1-5 every 4 weeks and V was given i.v. at a dose of 3.0 mg/m2 day 1 weekly. P was given i.v. at a dose of 100 mg/m2 day 1 every 4 weeks. There was no statistically significant difference in overall survival between the treatment arms (P = 0.22). Increased toxicity was observed in the treatment arm containing P of which leucopenia, alopecia and nausea/vomiting were the most pronounced. The median time to progression was significantly longer in patients treated with DVP (4.2 versus 2.2 months, P = 0.007). In conclusion, adding P to DV did not change overall survival but did significantly increase toxicity.

Ringborg, U.; Jungnelius, U.; Mansson-Brahme, E.; Cedermark-Cohn, G.; Hansson, J. Author Information

Department of Oncology, Radiumhemmet, Karolinska Hospital, Stockholm and 1Department of Biochemistry, Biomedical Centre, Uppsala University, Uppsala, Sweden

DNA ploidy and S-phase fraction were measured by dow cytometry in the tumour tissue of 87 patients with disseminated malignant melanoma, who had been classified either as responders or with progressive disease in a study of the effects of 2 chemotherapeutic regimens. The patients had been randomized to receive treatment with dacarbazine (DTIC) and vindesine (Eldesine) with or without addition of cisplatin (Platinol). Tumour tissue was obtained from both the primary tumours and the last histologically verified metastases, but in some cases only the primary tumours or the last metastases could be evaluated. There was a significantly higher mean S-phase value in melanoma metastases from patients with complete or partial responses compared with patients with progressive disease. Neither the S-phase fraction of the primary tumour nor the DNA ploidy of the primary tumour or of the last histologically verified metastases taken before inclusion into the study were associated with therapeutic response. In the multivariate analysis, both the anatomical location of the metastases and the S-phase fraction measured on the last metastases remained significant prognostic factors of response. In the univariate survival analysis, there was an association between high S-phase fractions of the metastases and longer survival. In the multivariate survival analysis, the S-phase fraction, the number of involved metastatic sites and the treatment response were independent predictive factors. We conclude that, in disseminated melanoma treated with chemotherapy, a high S-phase fraction measured in the last histologically verified metastases is associated with a higher response rate and a longer survival. Our results clearly support the role of S-phase measurement as a potential tool for selecting patients for treatment. (C) 1996 Wiley-Liss, Inc.

Expression of the detoxication enzyme glutathione transferase P1-1 (GST P1-1) at elevated levels has been noted in many types of human tumors, including melanomas. The products of the human H-RAS, K-RAS and N-RAS genes play a key role in intracellular signal transduction leading to transcriptional activation of AP-1 (Fos/Jun) responsive genes. The oncogenic mutated forms of the ras proteins are constitutively active and interfere with normal signal transduction. Mutated RAS genes as well as increased expression of wild-type ras proteins are common features in human tumors including melanoma. We have characterized 30 melanoma metastases from 23 melanoma patients with reference to N-RAS expression and mutation as well as to GST P1 expression (immunohistochemistry and genetic analysis). Twenty-three of 30 samples (70%) had high N-Ras p21 and/or N-RAS codon 61 mutations and 18 of these 23 samples also had high GST P1-1 immunoreactivity. Seven of 30 (23%) samples had low N-Ras p21 immunoreactivity and no detectable N-RAS codon 61 mutations. Six of these 7 samples (86%) also had low GST P1-1 immunoreactivity. The results indicate a statistically significant correlation (Spearman correlation coefficient, r = 0.56, p = 0.001, 2-tailed test) and provide, for the first time, indirect evidence for a possible coregulation of N-RAS and GST P1 in human malignant melanoma which should be further evaluated.

In a phase III study of disseminated malignant melanoma performed in Sweden and Norway, 326 patients were randomized to receive treatment with the combination Dacarbazine (OTIC) and Vindesine (VDS) with or without addition of Cisplatin (CDDP). The study was designed to reveal a clinically significant survival difference when the three drugs were combined. DTIC was given i.v. at a dose of 250 mg/sqm days 1 to 5 every four weeks and VDS was given i.v. at a dose of 3.0 mg/sqm day 1 weekly. CDDP was given i.v. at a dose of 100 mg/sqm day 1 every 4 weeks. There was no statistical significant difference regarding total survival between the treatment arms (P = 0.22). What was clearly demonstrated was an increased toxicity in the treatment arm containing CDDP. Two hundred and sixteen patients were evaluable for response in compliance with the WHO criteria. With the DTIC-VDS regimen 9.9% patients obtained a complete remission and 10.8% patients a partial remission with an overall response rate of 20.7%. With the triple regimen DTIC-VDS-CDDP 16.2% patients obtained a complete remission and 15.2% patients a partial remission with an overall response of 31.4%. The difference in objective response rates observed between the treatment arms is not statistically significant (P = 0.1011). In conclusion this study did not show any significant increases in median survival time or objective response rate. The study has demonstrated a clinically significant increase in toxicity and we suggest that this triple regimen does not merit further use in patients with disseminated malignant melanoma, which earlier phase II studies have indicated. In a phase III study of disseminated malignant melanoma performed in Sweden and Norway, 326 patients were randomized to receive treatment with the combination Dacarbazine (OTIC) and Vindesine (VDS) with or without addition of Cisplatin (CDDP). The study was designed to reveal a clinically significant survival difference when the three drugs were combined. DTIC was given i.v. at a dose of 250 mg/sqm days 1 to 5 every four weeks and VDS was given i.v. at a dose of 3.0 mg/sqm day 1 weekly. CDDP was given i.v. at a dose of 100 mg/sqm day 1 every 4 weeks. There was no statistical significant difference regarding total survival between the treatment arms (P = 0.22). What was clearly demonstrated was an increased toxicity in the treatment arm containing CDDP. Two hundred and sixteen patients were evaluable for response in compliance with the WHO criteria. With the DTIC-VDS regimen 9.9% patients obtained a complete remission and 10.8% patients a partial remission with an overall response rate of 20.7%. With the triple regimen DTIC-VDS-CDDP 16.2% patients obtained a complete remission and 15.2% patients a partial remission with an overall response of 31.4%. The difference in objective response rates observed between the treatment arms is not statistically significant (P = 0.1011). In conclusion this study did not show any significant increases in median survival time or objective response rate. The study has demonstrated a clinically significant increase in toxicity and we suggest that this triple regimen does not merit further use in patients with disseminated malignant melanoma, which earlier phase II studies have indicated.

Glutathione transferases (GSTs) are enzymes involved in the resistance of tumor cells to bifunctional alkylating cytostatic drugs. We investigated the melphalan sensitivity together with activity and cellular concentration of GST isoenzymes of human melanoma cell line RPMI 8322 in different phases of the cell cycle. By centrifugal elutriation three cell fractions containing different proportions of cells in the G1 phase were isolated. Melphalan sensitivity was estimated by the colony formation assay. The cell fraction with the largest proportion of G1 cells was more sensitive to the drug than the fractions enriched in S and G2 cells. The GST activity of the cell fractions was measured with 1-chloro-2,4-dinitrobenzene (CDNB) as substrate and the concentrations of GST P1-1, GST M1-1 and GST A1-1 were quantitated by use of isoenzyme-specific ELISA. The results show that there were less GST activity and lower GST P1-1 and A1-1 concentrations in the G1 cell enriched fraction, demonstrating a cell cycle dependence of GST expression. Thus, the cell fraction most sensitive to melphalan had the highest proportion of G1 cells and displayed the lowest GST activity, suggesting that the cell cycle dependent sensitivity to melphalan may at least partially depend on the expression of GSTs.

Sixteen healthy donors were investigated for the presence or absence of glutathione transferase (GST) M1-1 in lymphocytes by immunodetection with polyclonal antibodies against human GST M1-1. Nine out of 16 individuals (56%) were categorized as GST M1-1 positive. Phytohaemagglutinin stimulated lymphocytes from GST M1-1 positive and negative donors were treated with 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) and compared regarding inhibition of [3H]thymidine incorporation as a measure of cytotoxicity. No significant differences in the effect of BCNU were observed between the two groups, indicating that GST M1-1 is not an important resistance factor for BCNU.

Glutathione transferases are enzymes implied in the resistance of tumor cells to bifunctional alkylating cytostatic drugs. We have investigated the effect of the glutathione transferase inhibitor by ethacrynic acid on the cytotoxicity of melphalan to a human melanoma cell line (RPMI 8322) with a high level of glutathione transferase activity. Using 1-chloro-2,4-dinitrobenzene as substrate, ethacrynic acid was shown to inhibit the activity of purified human glutathione transferases, with 50% inhibition values of 1, 10, and 15 microM for transferase mu (class mu), transferase epsilon (class alpha) and transferase pi (class pi), respectively, all of which occur in RPMI 8322 cells. Ethacrynic acid at a concentration of 20 microM, which by itself was noncytotoxic, increased the cytotoxicity of melphalan to RPMI 8322 human melanoma cells approximately 2-fold. The induction of DNA interstrand cross-links by 40 microM melphalan was increased 1.4-fold by 30 microM ethacrynic acid. These results indicate that a potentiation of the cytotoxic effect of bifunctional alkylating agents can be achieved by inhibition of glutathione transferase and that the enhanced cytotoxicity may be caused at least in part by increased formation of drug-DNA adducts.

Dacarbazine-vindesine-cisplatin treatment was evaluated in a phase II study of patients with disseminated malignant melanoma alter the dose of eisplatin had been determined in a phase I study. Dose of dacarbazine was 250 mg/m2 × V every 4 weeks, vindesine 3 mg/m2 once every week, and eisplatin 100 mg/m2 every 4 weeks. Forty patients with advanced disseminated malignant melanoma are available for response. Complete remissions were obtained in three patients (8%) and partial remissions in 12 patients (30%). The total response rate was 38%. Median response duration was 4 months. Toxicity was unacceptable in live cases (nephrotoxicity. one patient: ototoxicity. two patients: hypotonia. one patient: gastrointestinal toxicity, one patient). The conclusion is that the combination dacarbazine-vindesine-cisplatin gives rise to a high response rate in patients with advanced disseminated malignant melanoma. Despite its considerable toxicity, the regimen should be tested on patients with a limited tumor burden.

Fifty‐four patients with metastatic cancer were followed audiometrically during high‐dose (100‐120 mg/m 2 ) cisplatin chemotherapy. Eighty‐one percent of the patients showed significant changes in air‐conduction hearing thresholds after completion of therapy. Thirteen percent sustained a significant hearing handicap. An interindividual variation was found, ranging from severe hearing loss after the first course to unaffected hearing after three courses. The oto‐toxic effect was not increased by pre‐existing hearing loss, but was slightly increased by age. The risk was determined more by the amount of the single dose than by the cumulative dose. The further ototoxic effect could not be predicted on the basis of the audiogram after the first coursa Peak plasma concentration of platinum was measured in eight patients, and no ototoxic changes were noted below a concentration of 1 μg/L.

Melphalan inhibits the incorporation of 3H-thymidine and 3H-uridine significantly more in phytohaemagglutinin (PHA)-stimulated human lymphocytes than in a human melanoma cell line (RPMI 8322). Melphalan - induced total DNA cross-linking was 1.7 times higher and DNA interstrand cross-linking was 1.8 times higher in the PHA-stimulated lymphocytes than in the melanoma cells. A higher level of DNA cross-linking was required in melanoma cells than in PHA-stimulated lymphocytes to obtain similar levels of inhibition of incorporation of 3H-thymidine and 3H-uridine. The outflow of cells from G1 to S phase was significantly more inhibited by melphalan in the lymphocytes than in the melanoma cells. Thus the melanoma cells can replicate and transcribe DNA in the presence of levels of DNA damage, which in PHA-stimulated lymphocytes strongly inhibit DNA and RNA synthesis.