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Journal of Clinical Oncology, Vol 22, No 16 (August 15), 2004: pp. 3366-3374 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.12.007 Phase I and Pharmacokinetic Study of the Novel Oral Cell-Cycle Inhibitor Ro 31-7453 in Patients With Advanced Solid TumorsFrom the Developmental Chemotherapy Service and the Thoracic Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center and the Joan and Sanford I. Weill Medical College of Cornell University, New York, NY; Hoffmann-La Roche Inc, Nutley, NJ Address reprint requests to Jakob Dupont, MD, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; e-mail: dupontj{at}mskcc.org
PURPOSE: To determine maximum tolerated dose, pharmacokinetics (PK), and safety of Ro 31-7453, a novel, oral cell-cycle inhibitor. PATIENTS AND METHODS: Using an accelerated dose-escalation schedule, 48 patients with advanced solid tumors were treated with doses of Ro 31-7453 ranging from 25 to 800 mg/m2/d given for 4 consecutive days, every 3 weeks. The total daily dose was taken as a single dose (schedule A) or divided into two equal doses taken 12 hours apart (schedule B). PK samples of blood and urine were collected on the first and last days of dosing in cycles 1 and 2. RESULTS: Forty-five patients completed at least one cycle of therapy. Myelosuppression and stomatitis were dose-limiting toxicities, occurring at the 800 mg/m2/d dose level for both schedules. Toxicity was independent of body-surface area, leading to the recommended phase II flat dose of 1,000 mg daily for 4 days for both schedules. Common adverse events included diarrhea, nausea, vomiting, fatigue, alopecia, and elevated liver-function tests. One death, related to neutropenic sepsis, occurred on study. The PK of the parent compound and major metabolites were apparently linear, with a half-life of approximately 9 hours and a maximum concentration of approximately 4 hours. Minor antitumor activity was observed against carcinoma of the lung, breast, pancreas, and ovary. CONCLUSION: Ro 31-7453 was well tolerated, with manageable adverse effects. Significant PK variability (absorption, metabolism, and excretion) was observed, and a substantial number of additional patients are needed to confirm the recommended phase II dose. Additional pharmacology and phase II studies are under way to explore the dose-toxicity relationship.
In normal eukaryotic cell cycling, the transition from one phase to the next is controlled by an orderly succession of cyclins partnered with their corresponding cyclin-dependent kinases (CDKs).1 Recent studies indicate that CDK deregulation is an almost universal feature of cancer pathogenesis.2 Alterations in the cyclins and CDKs involved in the G1 phase (ie, cyclin D and CDKs 4 and 6), in particular, have been found in a wide range of human tumors.3-5 In addition, M-phase (mitosis), which involves the separation and division of cellular constituents in the formation of two identical progeny, is critical in tumor proliferation. The cell cycle has been targeted by many antineoplastic agents. As such, CDK function may be manipulated by direct inhibition (purine analogues, butyrolactone, staurosporine, and a staurosporine derivative, UCN-01),6-8 indirectly, by altering CDK modulators (rapamycin, herbimycin, and flavorpiridol), or by both mechanisms (flavopiridol).9-11 Early clinical studies with flavopiridol12 and UCN-0113 have been reported; both of these agents are currently being studied in combination with other chemotherapy regimens, as well as in disease-specific trials. Another common target is the mitotic process of the cell cycle. Chemotherapeutic agents that alter microtubules and thereby alter the mitotic process include the taxanes (eg, paclitaxel14 and docetaxel) and the vinca alkaloids (eg, vincristine and vinblastine), as well as the epothilons,15 which are currently being explored in clinical trials. Ro 31-7453 at low concentrations inhibits mitotic spindle formation, leading to M-phase arrest followed by apoptosis. In addition, this agent is a weak inhibitor of CDKs 1, 2, and 4, and tubulin polymerization in cell-free systems.16 Antitumor effects have been observed in a wide range of cancer cell lines and in vivo tumor models, including five of five multidrug-resistant cell lines.16 After oral administration in several animal species, Ro 31-7453 was extensively metabolized to metabolites Ro 27-4006, Ro 27-0431, Ro 27-0997, and Ro 27-1050 (Fig 1). In vitro human liver microsomal data identified CYP3A4 as the principal metabolizing enzyme of Ro 31-7453. Two metabolites (Ro 27-0431 and Ro 27-0997) are the result of N-demethylation—Ro 27-4006 is an N-methylhydroxy metabolite, and Ro 27-1050 is formed through N,N-didemethylation. Ro 27-0431 and Ro 27-4006 exhibited in vitro antiproliferative and cell-cycle inhibitory activity similar to the parent compound, whereas Ro 27-0997 and Ro 27-1050 were much less potent.17 In preclinical studies, reversible toxic effects involved the bone marrow, intestine, liver, and lymphoid tissues.
We conducted this phase I study to determine the maximum tolerated dose (MTD), the pharmacokinetics, and safety profile of Ro 31-7453. The final study results are reported in this article.
Patient Selection Eligible patients were required to have a diagnosis of advanced carcinoma with no known curative therapy. Laboratory requirements included hemoglobin  9 g/dL, WBC count 3,000/mm3, absolute neutrophil count 1,500/mm3, platelets 100,000/mm3, serum bilirubin  1.5x the institutional upper limit of normal (ULN), AST and ALT 2.5x ULN ( 4x ULN if liver metastases were present), and serum creatinine 1.5x ULN (or a creatinine clearance > 60 mL/min). Exclusion criteria included the following: (1) a Karnofsky performance status 60%; (2) CNS metastases; or (3) receipt of an investigational drug, chemotherapy, radiation therapy, or biologic therapy within 4 weeks before study day 1. Memorial Sloan-Kettering Cancer Center’s institutional review board approved the study, and written informed consent was obtained from enrolled patients.
Clinical Study Design
The first patient received Ro 31-7453 at a starting dose of 25 mg/m2 on schedule A. If there were no instances of treatment-related toxicity
DLT was defined as (1)
Treatment Assessment
Pharmacokinetic Study Plasma samples and aliquots (15 to 20 mL) of the total 24-hour urine collection were stored at –70°C or at –20°C and shipped immediately to Hoffmann-La Roche Inc for analysis. A predosing urine sample was collected as a control on day 1 only. The maximum concentration, time to maximum serum concentration, area under the concentration-time curve (AUC), and apparent half-life were determined for Ro 31-7453 and metabolites.
Pharmacodynamic Study
Analytic Method The LC/MS/MS method for the determination of Ro 31-7453 and its four metabolites, Ro 27-0431, Ro 27-0997, Ro 27-1050, and Ro 27-4006, was validated in a single sample for the concentration range 0.2 ng/mL (the limit of quantitation) to 200 ng/mL for all analytes. After addition of an internal standard (isotopically labeled Ro 31-7453-13C6), the analytes were isolated from EDTA in human plasma by liquid-liquid extraction into an ethyl acetate/isopropyl alcohol mixture, concentrated, separated by high-performance liquid chromatography, and measured by positive ion turbo ion spray MS/MS. The precision (average % coefficient variation) for Ro 31-7453, Ro 27-0431, Ro 27-0997, Ro 27-1050, and Ro 27-4006 was 3.00%, 3.35%, 3.75%, 4.70%, and 8.12%, respectively. The accuracy (percent of bias) ranged from –1.46% to 0.95%, –2.10% to 2.42%, –2.32% to 2.09%, –2.93% to 2.40%, and –1.64% to 2.77%, for Ro 31-7453, Ro 27-0431, Ro 27-0997, Ro 27-1050, and Ro 27-4006, respectively.
Patient Characteristics and Treatment Administration Forty-eight patients were accrued and received at least one dose of study drug. The median age of patients was 56 years (range, 37 to 80 years), the male-female ratio was 20:28 (42%:58%), and the median Karnofsky performance status was 80% (range, 70% to 90%). The median number of prior chemotherapeutic, hormonal, or immune regimens was four (range, one to nine). Primary diagnoses were cancer of the lung (n = 10), colorectum (n = 5), breast (n = 5), head and neck (n = 4), bladder (n = 4), ovary (n = 4), sarcoma (n = 4), kidney (n = 3), endometrium (n = 2), prostate (n = 2), pancreas (n = 1), melanoma (n = 1), unknown primary (n = 1), esophagus (n = 1), and stomach (n = 1). Seven dose levels of Ro 31-7453, ranging from 25 mg/m2/d to 800 mg/m2/d, were evaluated; 18 and 30 patients were treated on schedules A and B, respectively. The median number of cycles administered was two (range, one to six). Thirty-nine (81%) of 48 patients came off of study because of progression of disease; six patients were removed from the study because of toxicity; and three patients were removed because of intercurrent illness.
Hematologic Toxicity
Ten patients (21%) experienced thrombocytopenia (eight patients with grade 1 or 2, and two patients with grade 3 or 4). There was only one episode of severe (grade 3) thrombocytopenia observed during the first cycle of therapy. Irrespective of cycle, the median time to thrombocytopenia was 11 days from day 1 of dosing in the cycle (range, 3 to 19 days), lasting a median of 8 days (range, 1 to 20 days). Anemia occurred in 38% of patients; five patients had grade 3 and 4 anemia.
Nonhematologic Toxicities Fourteen patients (31%) developed stomatitis (10 patients with grade 1 and 2 and four with grade 3 and 4), with 28% of the episodes occurring during cycle 1% and 72% during subsequent cycles. The mean duration of stomatitis was 14 days (range, 1 to 50 days). Grade 3 and 4 stomatitis occurred only in the presence of severe neutropenia, and recovered concurrently with the neutropenia. Two patients on schedule B developed grade 3 or 4 transaminase elevation, and one patient on schedule A developed grade 4 hyperbilirubinemia (Table 1).
Pharmacokinetics
Despite large intersubject variabilities (30% to 60%), the AUC and trough concentrations of Ro 31-7453 and its active metabolites tended to increase at higher doses. A comparison of cycle 1 versus cycle 2 peak and trough levels of Ro 31-7453 and its active metabolites was performed. Overall, the data suggest that there was no substantial change in pharmacokinetics parameters from cycle 1 to cycle 2 dosing. Urine samples from patients treated at the highest dose level on schedule B were screened for the presence of Ro 31-7453 and major metabolites, and the detectable levels were less than 1% of the total dose. Figure 3 depicts the relationship between dose and apparent oral clearance of the parent drug, as well as clearance of the two active species on the first dosing day. The data suggest that apparent oral clearance of the parent drug is dose independent and thus shows apparent linear pharmacokinetics (for Ro 31-7453). Clearance of Ro 27-4006 also seems to be linear. Due to large interpatient variability, the same relationship for Ro 27-0431 is somewhat less clear. A regression analysis of clearance against dose administered showed no significant dose dependence for any of the three active species across the 400- to 800-mg/m2 dose range, implying linearity of absorption/elimination. Figure 4 shows a lack of correlation between body-surface area (BSA) dose and apparent oral clearance (for the parent), and clearance (for the metabolites), suggesting that the pharmacokinetics are independent of BSA.
Pharmacodynamics The pharmacodynamic analysis was focused on neutropenia because this toxicity became a DLT in the present study. Separate modeling was not performed for the two schedules because of indistinguishable correlations between the two schedules, and limited data points for schedule A. Pharmacodynamic effects of Ro 31-5473 on patient neutrophil and total WBC counts were evaluated using pre- and postdrug (nadir) neutrophil and WBC counts of patients receiving Ro 31-7453.
In a multiple linear regression model of leukocyte toxicity incorporating total daily dose, the AUC of the parent drug provided no additional predictive value. In contrast, AUC of metabolite 1 (Ro 27-4006) was associated with a significant suppression of both neutrophils (P = .003) and total WBCs (P = .036). Addition of metabolite 2(Ro 27-0431) provided limited additional information (P = .126). In a model with total daily dose, a summation of AUCRo 31-7453, AUCRo 27-4006, and AUCRo 27-0431 provided the best additional factor for predicting both neutrophil (P Although preclinical data suggest that Ro 31-7453 is highly protein bound, neither albumin nor total protein was associated with toxicity.
DLT and MTD
The future studies of Ro 31-7453 should utilize a flat dose rather than a BSA normalized dosing plan. The recommended phase II dose for Ro 31-7453 was established as 560 mg/m2. This corresponds to a flat dose of approximately 1,000 mg for 4 consecutive days in both schedules. This dose was consistently safe and could be readily explored further. A dose of 800 mg/m2 (approximately 1,400 mg) for 4 days was very myelosuppressive in this phase I population, but might be acceptable for a less heavily pretreated group. The intermediate dose of 680 mg/m2 (approximately 1,200 mg) seemed to be acceptable, as was the 340 mg/m2 (approximately 600 mg) twice-daily schedule, though that dose also gave a high frequency of myelosuppression when grades 3 and 4 toxicity were combined (Table 1).
Antitumor Activity
In this study, we present the results of the initial phase I dose-escalation study of the novel oral cell cycle inhibitor Ro 31-7453, which inhibits CDKs 1, 2, and 4, as well as tubulin polymerization in cell-free systems. Interestingly, the toxicity profile of Ro 31-7453 is not characteristic of other known cell-cycle inhibitors, such as UCN-01 and flavopiridol. The commonly reported adverse events with these two established cell-cycle inhibitors included nausea, vomiting, diarrhea, and headache,12,13 whereas forRo 31-7453, the major toxicities were myelosuppression, stomatitis, and alopecia, which are consistent with traditional cytotoxic agents, including the mitotic spindle inhibitors such as taxanes and the epothilones. The DLTs for UCN-01 were hyperglycemia, nausea, vomiting, and hypotension.13 The DLTs for flavopiridol were fatigue, diarrhea, and deep-vein thrombosis.12 It should be noted, however, that neutropenia has emerged as a DLT for flavopiridol when administered on a variety of intermittent bolus schedules.19 The broad range of adverse reactions suggests that both UCN-01 and flavopiridol are not selective inhibitors of any one CDK, but rather that they affect numerous targets in the cell-cycle pathway. By contrast, the observed adverse event profile seen with Ro 31-7453 does not mirror the toxicity profile of the known cell-cycle inhibitors, suggesting that its primary activity is more like the mitotic spindle inhibitors. Ro 31-7453 is rapidly absorbed, with maximum concentration attained within 2.5 to 5 hours after oral administration at the MTD (Table 2). Ro 31-7453 and its metabolites were comparable in terms of half lives, suggesting a metabolite-formation–limiting step (Fig 2). Since preclinical data suggest that Ro 31-7453 and its major metabolites were equally potent, with a comparable toxicological profile, these three species were added for each patient as an index of total systemic exposure. In fact, pharmacodynamic modeling revealed that summation AUC of parent compound (Ro 31-7453) and the two active metabolites (Ro 27-4006 and Ro 27-0431), rather than any one species alone, had the greatest effect on neutrophil and WBC toxicity. There was moderate inter- and intrapatient variability in AUC in this patient population (48% and 28%, respectively). This AUC variability between patients likely explains why DLT was noted at a variety of dose levels. Other patient characteristics were evaluated as possible correlates with increased toxicity, and no other associations were noted. Although the drug was highly bound to albumin in preclinical studies, there was no association between patient albumin levels and toxicity. Total dose seemed to be correlated with toxicity. Since there was a lack of association between BSA and apparent oral clearance, BSA-based dosing will not be required in future trials, and a flat dosing scheme can be used, simplifying the preparation of this oral formulation. There appeared to be slightly greater toxicity on schedule B (twice-daily dosing). This might be attributable to the higher Ctrough levels noted on this schedule (Table 2). Of note, pharmacokinetics were assessed on day 1 after the first of two daily doses of Ro 31-7453 on schedule B and after the only dose on day 1 of schedule A. This minor difference could have had an effect on the pharmacodynamic comparison of the two schedules. The pharmacokinetic variability of Ro 31-7453 makes establishing the recommended phase II dose difficult. Certainly, a dose of 560 mg/m2 is an acceptable dose (two DLTs per 15 total patients), either as a single daily dose or as a divided dose given twice daily. This corresponds to a flat dose of approximately 1,000 mg daily for 4 days. The 340 mg/m2 twice-daily dose was technically safe, though substantial myelosuppression was present in this group of heavily pretreated patients (one DLT per six patients). This dose would be approximately 1,200 mg for 4 days. The 800 mg/m2 dose is probably too toxic for routine phase II dosing (four DLTs per 14 patients). The variation in toxicity may be related to variations in disease and prior therapy, absorption, or elimination of the drug and its active metabolites. The pharmacokinetic and toxicity variability indicated that many additional patients would be required to further clarify the dose-response curve. It seemed most appropriate to conclude this trial with the 35 patients treated in the proposed phase II dose range (560 to 800 mg/m2) and begin additional trials with a more uniform disease and prior-therapy profile. A flat dose of 1,000 to 1,200 daily for 4 days is recommended. The recommended choice of schedule was also controversial. The t1/2 of the drug suggested that once-daily dosing is certainly possible, and the total AUC was similar to the twice-daily dosing. However, the trough drug levels were substantially lower, and the twice-daily schedule resulted in a more uniform plasma-concentration profile. This has theoretical benefits for an agent that seems to act at a specific point in the cell cycle. As a consequence, exploration of an intermediate (680 mg/m2) single daily dose was omitted. Instead, we elected to initiate a second trial at 340 mg/m2 twice daily for 4 days to explore the effect of food intake on Ro 31-7453 absorption, bioavailability, and toxicity in a less heavily pretreated population. That study was conducted by other investigators and will be reported separately. The current study reflects some of the difficulties in the development of an oral agent with active metabolites and large interpatient variability. Current phase I designs do not generally encompass the large number of patients needed to securely define an appropriate empiric dose. It is possible that additional pharmacologic investigations in specific populations could produce a dosing scheme based on adaptive dosing. Preclinically, Ro 31-7453 is active in paclitaxel-resistant tumor models. In addition, it has additive or synergistic activity with other cytotoxic chemotherapeutic agents. Examples include combination with paclitaxel against breast carcinoma cell lines,16 with gemcitabine against an non–small-cell lung cancer tumor model,20 and with capecitabine against mammary and colorectal xenograft models.21 In the current study, five of the six patients who had minor responses to treatment had received prior taxane therapy and were presumed to be taxane resistant. Also, unlike the other mitotic-spindle–targeted therapies, including taxanes, vinca alkaloids, and the epitholones, in which neuropathy is a limiting factor, Ro 31-7453 had no associated neurotoxicity. However, it did share other common associated toxicities, such as myelosuppression and alopecia. Considering the toxicity profile of Ro 31-7453 and the clinical responses noted in this study, as well as the preclinical data showing additive or synergistic antitumor activity with other cytotoxic agents, including paclitaxel, Ro 31-7453 warrants further investigation. This study suggests that the orally active, novel cell-cycle inhibitor Ro 31-7453 is well tolerated, with manageable adverse effects at the MTD. Ro 31-7453 shows promise in several tumor types, based on antitumor activity seen in this study. Phase I/II studies of Ro 31-7453 in combination with gemcitabine and paclitaxel, respectively, have been initiated.
The following authors or their immediate family members have indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. Owns stock (not including shares held through a public mutual fund): Mark DeMario, Roche.
Supported in part by funds granted by the Charles H. Revson Foundation, the American Society of Clinical Oncology Young Investigator and Career Development Awards, and by funds from the Lymphoma Foundation. Presented in part at the 37th Annual Meeting of the American Society of Clinical Oncology, San Francisco, CA, May 12–15, 2001. Authors’ disclosures of potential conflicts of interest are found at the end of this article.
1. Senderowicz AM, Sausville EA: Preclinical and clinical development of cyclin-dependent kinase modulators. J Natl Cancer Inst 92:376-387, 2000
2. Sherr CJ: Cancer cell cycles. Science 274:1672-1677, 1996
3. Hartwell LH, Kastan MB: Cell cycle control and cancer. Science 266:1821-1828, 1994 4. Harper J, Elledge S: CDK inhibitors in development and cancer. Curr Opin Genet Dev 6:56-64, 1996[CrossRef][Medline] 5. Cordon-Cardo C: Mutations of cell cycle regulators: Biological and clinical implications for human neoplasia. Am J Pathol 147:545-560, 1995[Abstract]
6. Carlson BA, Dubay MM, Sausville EA, et al: Flavopiridol induces G1 arrest with inhibition of cyclin-dependent kinase (CDK) 2 and CDK4 in human breast carcinoma cells. Cancer Res 56:2973-2978, 1996
7. Wang Q, Fan S, Eastman A, et al: UCN-01: A potent abrogator of G2 checkpoint function in cancer cells with disrupted p53. J Natl Cancer Inst 88:956-965, 1996 8. Meijer L, Kim SH: Chemical inhibitors of cyclin-dependent kinases. Methods Enzymol 283:113-128, 1997[Medline]
9. Carlson B, Lahusen T, Singh S, et al: Down-regulation of cyclin D1 by transcriptional repression in MCF-7 human breast carcinoma cells induced by flavopiridol. Cancer Res 59:4634-4641, 1999
10. Hashemolhosseini S, Nagamine Y, Morley SJ, et al: Rapamycin inhibition of the G1 to S transition is mediated by effects on cyclin D1 mRNA and protein stability. J Biol Chem 273:14424-14429, 1998 11. Yamada H, Iwase S, Nagai M, et al: Herbimycin A down-regulates messages of cyclin D1 and c-myc during erythroid differentiation of K562 cells. Int J Hematol 65:31-40, 1996[CrossRef][Medline]
12. Schwartz GK, O’Reilly E, Ilson D, et al: Phase 2 study of the cyclin-dependent kinase inhibitor flavopiridol administered to patients with advanced gastric carcinoma. J Clin Oncol 19:1985-1992, 2001
13. Sausville EA, Arbuck SG, Messmann R, et al: Phase I trial of 72-hour continuous infusion UCN-01 in patients with refractory neoplasms. J Clin Oncol 19:2319-2333, 2001 14. Schiff PB, Fant J, Horwitz SB: Promotion of microtubule assembly in vitro by Taxol. Nature 277:665-667, 1979[CrossRef][Medline]
15. Bollag DM, McQueney PA, Zhu J, et al: Epothilones, a new class of microtubule-stabilizing agents with a Taxol-like mechanism of action. Cancer Res 55:2325-2333, 1995 16. Investigational Brochure: Ro 31-7453. Nutley, NJ, Hoffmann-La Roche Inc, 1999 17. Dhingra U, Thomas M, Bertasso A, et al: Identification and preclinical characterization of metabolites of Ro 31-7453, a new cell-cycle inhibitor. Proc Am Assoc Cancer Res 41:31, 2000 (abstr 199)
18. Simon R, Freidlin B, Fubinstein L, et al: Accelerated titration design for Phase I clinical trials in oncology. J Natl Cancer Inst 89:1138-1147, 1997
19. Tan AR, Headlee D, Messmann, et al: Phase I clinical and pharmacokinetic study of flavopiridol administered as a daily 1-hour infusion in patients with advanced neoplasms. J Clin Oncol 20:4074-4082, 2002 20. Luistro LL: Antiproliferative and antitumor effects of Ro 31-7453 and gemcitabine alone and in combination against non-small cell lung carcinoma (NSCLC) models. Proc Am Assoc Cancer Res 42:82, 2001 (abstr 440) 21. Mortensen JH, et al: Antiproliferative and antitumor effects of Ro 31-7453 and capecitabine (Xeloda) alone and in combination against mammary and colorectal xenograft models. Proc Am Assoc Cancer Res 42:297, 2001 (abstr 1596) Submitted December 2, 2002; accepted May 11, 2004. This article has been cited by other articles:
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
