Phase I/II multicenter, randomized, open-label trial of the c-Met inhibitor MSC2156119J and gefitinib versus chemotherapy as second-line treatment in patients with MET-positive (MET+), locally advanced, or metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor mutation (EGFRm+) and progression on gefitinib.
Yi‐Long WuJames Chih‐Hsin YangKeunchil ParkLianzhe XuFriedhelm BladtAndreas JohnePeiqi LiHongxia ZhengGiorgio Massimini
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TPS8121 Background: Resistance to EGFR tyrosine kinase inhibitors (eg, gefitinib) in EGFRm+ NSCLC patients (pts) is mainly caused by a secondary mutation in the EGFR (ie, T790M) or by activation of the c-Met/HGF signaling pathway (eg, protein overexpression and/or amplification). MSC2156119J, a highly selective small-molecule c-Met inhibitor, displayed promising antitumor activity in pts with advanced solid tumors in a Phase I trial (Falchook et al. J Clin Oncol 2013:31(Suppl):2506). This Phase Ib/II, multicenter, open-label trial investigates the antitumor activity of MSC2156119J + gefitinib in pts with MET+ advanced EGFRm+ NSCLC (NCT01982955). Methods: Primary objectives are determination of the recommended phase II dose (RP2D) for the combination (Phase Ib), and progression-free survival (PFS) per investigator read (Phase II). Secondary objectives include safety, pharmacokinetics, and antitumor activity of MSC2156119J (PFS per independent read, overall survival, objective response, and disease control). Adults with advanced NSCLC with activating EGFR mutation, ECOG status 0–1, and resistance on 1st-line gefitinib (Phase II only) are recruited in mainland China, South Korea, Taiwan, and other Asian countries. Patients must have confirmed MET+ status, defined as either strong or moderate protein overexpression by immunohistochemistry, or MET gene amplification by in situ hybridization. Main exclusion criteria: life expectancy <3 mo, or prior EGFR targeting therapy other than gefitinib (Phase II only). For the Phase Ib part (3+3 design), 15–18 pts are planned to receive 300 or 500 mg MSC2156119J p.o. + 250 mg gefitinib p.o./d (21-d cycle); for the Phase II part, up to 200 pts are planned to be enrolled into 2 predefined subgroups according to their T790M mutation status and subsequently randomized 1:1 to RP2D MSC2156119J p.o. + 250 mg gefitinib p.o./d or 500 mg/m2 pemetrexed i.v. + 75 mg/m2 cisplatin i.v. on day 1 (max. of six 21-d cycles). Enrollment for Phase Ib began on Dec 23, 2013. Clinical trial information: NCT01982955.Keywords:
T790M
Background: Gefitinib (ZD 1839, Iressa) is a new anticancer agent; more specifically, it is a selective epidermal growth factor receptor tyrosine kinase inhibitor that is, widely used for various solid cancers, including lung cancer.Cutaneous adverse reactions induced by gefitinib have recently been reported; however, not much on this topic has been reported in the Korean literature.Method: We studied cutaneous adverse reactions of gefitinib in 23 patients who suffered with non-small cell lung cancer at Chonnam National University Hwasun Hospital from October 2004 to September 2005.Result: The patients ranged from 23-72 years old, and there were 17 patients with adenocarcinoma, 5 with squamous cell carcinoma and 1 with bronchioloalveolar carcinoma.The most common adverse reaction was acneiform eruptions in 15 patients (65.2%).This reaction appeared within 2 months after medication, and it didn't correlate with the therapeutic response and tumor type.Pruritus was the second most common reaction (39.1%), which was mild and generalized, especially around eyelid area.Xerosis (26.1%), exfoliation on palm and sole (21.7%), and paronychia (21.7%) followed.Hair breakage and intertrigo were rare adverse reactions.Conclusion: Various cutaneous adverse reactions were observed in patients with non-small cell lung carcinoma after gefitinib treatment.The skin complications could be alleviated with dermatologic consultations and treatments, skin complications could be alleviated.
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EGFR is frequently mutated and amplified in lung adenocarcinomas sensitive to EGFR inhibitors gefitinib and erlotinib. A secondary mutation, T790M, has been associated with acquired resistance but has not been shown to be sufficient to render EGFR mutant/amplified lung cancers resistant to EGFR inhibitors. We created a model for studying acquired resistance to gefitinib by prolonged exposure of a gefitinib-sensitive lung carcinoma cell line (H3255; EGFR mutated and amplified) to gefitinib in vitro. The resulting resistant cell line acquired a T790M mutation in a small fraction of the amplified alleles that was undetected by direct sequencing and identified only by a highly sensitive HPLC-based technique. In gefitinib-sensitive lung cancer cells with EGFR mutations and amplifications, exogenous introduction of EGFR T790M effectively conferred resistance to gefitinib and continued ErbB-3/PI3K/Akt signaling when in cis to an activating mutation. Moreover, continued activation of PI3K signaling by the PIK3CA oncogenic mutant, p110alpha E545K, was sufficient to abrogate gefitinib-induced apoptosis. These findings suggest that allelic dilution of biologically significant resistance mutations may go undetected by direct sequencing in cancers with amplified oncogenes and that restoration of PI3K activation via either a T790M mutation or other mechanisms can provide resistance to gefitinib.
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Non-small-cell lung cancers with epidermal growth factor receptor (EGFR) mutations are sensitive to EGFR tyrosine kinase inhibitors (TKIs); however, unlike cytotoxic agents, it is generally accepted that minimal doses of drugs inhibiting target molecules are sufficient when molecular-targeted agents, including EGFR-TKIs, are used. Thus, any utility of higher doses remains unclear. We compared low-dose (15 mg/kg) gefitinib therapy with high-dose (50 mg/kg) therapy using an EGFR-mutated lung cancer xenograft model. Both gefitinib doses induced tumor shrinkage, but tumors regrew in the low-dose group within 1 month, whereas tumors in the high-dose group did not. Neither the T790M mutation nor MET amplification was apparent in regrown tumors. We also compared outcomes after two doses of gefitinib (5 and 25 mg/kg) in a transgenic EGFR-mutated lung cancer mouse model. In line with the results obtained using the xenograft model, both gefitinib doses completely inhibited tumor growth, but tumors treated with the lower dose of gefitinib developed earlier drug resistance. In conclusion, a low gefitinib dose caused tumors to become drug-resistant prior to acquisition of the T790M mutation or MET amplification in EGFR-mutated models of lung cancer. This suggests that it is important to optimize the EGFR-TKI dose for treatment of EGFR mutation-associated lung cancer. Gefitinib may need to be given at a dose greater than the minimum required for inhibition of target molecules.
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Although patients with non‑small cell lung cancer (NSCLC) experience an initial response to the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor gefitinib, those individuals with activating mutations in EGFR develop resistance. Gambogic acid (GA), a polyprenylated xanthone, has strong antitumor activities. In the present study, the therapeutic efficacy of gefitinib with GA was evaluated in a gefitinib‑resistant NSCLC model. The NCI‑H1975 cell line with EGFR‑T790M mutation was subcutaneously injected into immunocompromised mice. The mice were randomly assigned to receive treatment with gefitinib, GA, gefitinib plus GA, or vehicle for 4 weeks, then all mice were sacrificed and their tumor tissues were subjected to caspase activity detection and western blot analysis. Gefitinib and GA alone slightly inhibited the tumor growth of NCI‑H1975. However, the combined treatment significantly enhanced their antitumor effects, without any marked adverse events. In addition, gefitinib plus GA enhanced the level of apoptosis in the tumor tissues. Western blot analysis also revealed that the combination treatment reduced the phosphorylation level of AKT, MEK1/2 and ERK1/2, while an increased expression ratio of Bax/Bcl‑2 was observed. In the current study, gefitinib in combination with GA resulted in antitumor growth in the EGFR‑T790M secondary mutation NCI‑H1975 tumor model due to an enhanced apoptotic effect. This novel therapeutic strategy may be a practical approach for the treatment of patients who show gefitinib resistance.
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Gefitinib is an epidermal growth factor receptor (EGFR) inhibitor that is reported to be well tolerated and active in patients with chemotherapy-resistant non small cell lung cancer. On the other hand, gefitinib was also reported to produce a severe adverse event, interstitial lung disease, in less than 2% of treated patients. Given these circumstances, it is important to evaluate this drug and to establish its use clinically. We do not have sufficient data to evaluate gefitinib at this time. Phase III study of second/third line or maintenance therapy using gefitinib is required for such an evaluation. The development of individualized therapy with gefitinib might be also be required.
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Although the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors, such as gefitinib, have shown promising therapeutic efficacy in nonsmall cell lung cancer (NSCLC) patients harboring EGFR activating mutation, development of acquired resistance is almost inevitable. We investigated whether the addition of Epimedium koreanum Nakai extract (EEF) to gefitinib could overcome the resistance of NSCLC cells to gefitinib. In our study, the growth inhibitory effects of cotreatment differed between mutant EGFR and wild type EGFR. A synergistic antiproliferative effect was observed in the combined treatments in H1975 and PC-9GR cells carrying T790M EGFR. In addition, the cotreatment exhibited a much greater inhibition than either agent alone on the following metastatic processes: (a) invasion, (b) wound healing, and (c) tubule formation by endothelial cells. The phosphorylations of EGFR family (EGFR, HER-2, and HER-3) and EGFR downstream PI3K/Akt/mTOR pathway in H1975 and PC-9/GR cells were also attanuated, whereas EEF or gefitinib alone had no obvious effects. Similarly, the combination effectively suppressed tumor growth and increased mice survival in PC-9GR xenografts. The results indicate that the addition of EEF to gefitinib is a promising strategy to overcome T790M-mediated drug resistance.
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People’s lives and health are gravely threatened by non-small-cell lung cancer (NSCLC). Mutations in epidermal growth factor receptor (EGFR), a transmembrane receptor tyrosine kinase, are considered one of the causes of NSCLC. Tyrosine kinase inhibitors (TKIs) are typically used to treat patients with EGFR mutations. In this study, Gefitinib, a member of the first generation of TKIs, was used to treat an EGFR single-point mutation (single mutant, SM). Patients harboring additional T790M mutations in the kinase domain of the EGFR were resistant to Gefitinib. Then, the L858R/T790M double mutation (double mutant, DM) was treated with the second generation of TKIs, such as Afatinib. Here, we constructed four computational models to uncover the structural basis between EGFR mutants (SM and DM) and corresponding inhibitors (Gefitinib and Afatinib). The binding energy in the G-SM (representing Gefitinib in complex with SM) system was larger than that in the G-DM (Representing Gefitinib in complex with DM) system. Gefitinib’s affinity with L792 and M793 was drastically reduced by the longer side chain of M790 in the G-DM system, which pushed Gefitinib outside of the pocket. Additionally, the A-DM system’s binding energy was higher than the G-DM system’s. Afatinib, unlike Gefitinib, induced the P-loop region to move downwards to decrease the pocket entrance size to accommodate Afatinib properly and stably in the A-DM (Afatinib in complex with DM) system. These results uncover the details of interactions between EGFR and its inhibitors and shed light on the design of new tyrosine kinase inhibitors.
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