Randomised clinical trial: comparison of two everolimus dosing schedules in patients with advanced hepatocellular carcinoma

Alimentary Pharmacology and Therapeutics Randomised clinical trial: comparison of two everolimus dosingschedules in patients with advanced hepatocellular carcinoma H.-S. Shiah*,†,‡, C.-Y. Chen†, C.-Y. Dai§, C.-F. Hsiao¶, Y.-J. Lin**, W.-C. Su†, J.-Y. Chang*,†, J. Whang-Peng*,††,P.-W. Lin**, J.-D. Huang‡‡,1 & L.-T. Chen*,†,§,‡‡,1 *National Institute of Cancer Research, National Health ResearchInstitutes, Tainan, Taiwan.
† Department of Internal Medicine, National Cheng Kung University Deregulation of mammalian target of rapamycin (mTOR) signalling is com- Hospital, College of Medicine, mon in human hepatocellular carcinoma (HCC).
National Cheng Kung University, Tainan, Taiwan.
‡ Department of Internal Medicine, Division of Hematology and To determine the maximum tolerated dose (MTD) of the oral mTOR Oncology, Taipei Medical University inhibitor everolimus in advanced HCC patients.
Hospital, Taipei, Taiwan.
§Department of Internal Medicine and Cancer Center, Kaohsiung Medical Patients with locally advanced or metastatic HCC (Child-Pugh class A or B) University Hospital, Kaohsiung were enrolled in an open-label phase 1 study and randomly assigned to daily Medical University, Kaohsiung,Taiwan.
(2.5–10 mg) or weekly (20–70 mg) everolimus in a standard 3 + 3 dose-escala- ¶Institute of Population Health Sciences, tion design. MTD was based on the rate of dose-limiting toxicities (DLTs). Sec- National Health Research Institutes, ondary endpoints included safety, pharmacokinetics and tumour response. In a Zhunan, Miaoli County, Taiwan.
post hoc analysis, serum hepatitis B virus (HBV) DNA levels were quantified.
**Department of Surgery, NationalCheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
Thirty-nine patients were enrolled. DLTs occurred in five of 21 patients in ††Cancer Center Wan Fang Hospital, the daily and two of 19 patients in the weekly cohort. Daily and weekly Taipei Medical University, Taipei, Taiwan.
MTDs were 7.5 mg and 70 mg respectively. Grade 3/4 adverse events with a ‡‡Department of Pharmacology,  10% incidence were thrombocytopenia, hypophosphataemia and alanine College of Medicine, National ChengKung University, Tainan, Taiwan.
transaminase (ALT) elevation. In four hepatitis B surface antigen (HBsAg)-seropositive patients, grade 3/4 ALT elevations were accompanied by signifi- Correspondence to: cant (>1 log) increases in serum HBV levels. The incidence of hepatitis flare Dr L.-T. Chen, National Institute of (defined as ALT increase >100 IU/mL from baseline) in HBsAg-seropositive Cancer Research, National HealthResearch Institutes, 2F, No. 367, patients with and without detectable serum HBV DNA before treatment was Sheng-Li Road, Tainan 70456, Taiwan.
46.2% and 7.1% respectively (P < 0.01, Fisher exact test). Disease control rates in the daily and weekly cohorts were 71.4% and 44.4% respectively.
1L.-T. Chen and J.-D. Huangcontributed equally to the manuscript.
ConclusionsThe recommended everolimus dosing schedule for future hepatocellular carcinoma studies is 7.5 mg daily. Prophylactic anti-viral therapy should be Submitted 2 August 2012First decision 9 August 2012 mandatory for HBsAg-seropositive patients (ClinicalTrials.gov NCT00390195).
Resubmitted 27 September 2012 Accepted 16 October 2012 Aliment Pharmacol Ther 2013; 37: 62–73 EV Pub Online 8 November 2012 ª 2012 Blackwell Publishing Ltd Randomised clinical trial: phase 1 study of everolimus for advanced HCC and de novo tumour development, avoid rejection and In 2008, it is estimated that approximately 748 000 peo- improve OS in patients with HCC who undergo liver ple were diagnosed with liver cancer and that approxi- transplantation.18, 19 mately 695 000 individuals died of the disease globally.1 Everolimus has been extensively evaluated in patients Approximately 85–90% of primary liver cancers manifest with advanced solid tumours and is currently approved as hepatocellular carcinoma (HCC).2 Most patients with in various countries for the treatment of postmenopausal HCC present with co-existing cirrhosis caused primarily women with hormone receptor-positive, HER2-negative by chronic hepatitis B virus (HBV) and/or hepatitis C breast cancer in combination with exemestane after fail- virus (HCV) infection, chronic alcohol abuse or meta- ure of treatment with letrozole or anastrozole; adults bolic syndrome.2, 3 with metastatic renal cell carcinoma (mRCC) that pro- Therapies with curative potential, such as liver resec- gressed on previous VEGF-targeted therapy; adults with tion, liver transplantation and local ablation, are limited progressive pancreatic neuroendocrine tumours (pNET) to patients with early-stage HCC.4–6 However, the major- that are unresectable, locally advanced or metastatic; ity of patients present with advanced or metastatic dis- adults with renal angiomyolipoma associated with tuber- ease.7 In these patients, systemic cytotoxic chemotherapy ous sclerosis complex (TSC) not requiring immediate provides only a modest benefit.3, 4 HCC is a complex, surgery; and paediatric and adult patients with unresec- heterogeneous, highly vascularised tumour with evidence table subependymal giant cell astrocytomas associated of aberrant activation of multiple signaling cascades.2, 3 with TSC that require intervention. The recommended Therapies targeting these molecular pathways provide a everolimus dose in patients with breast cancer, mRCC new approach to address the unmet need of effective and pNET is 10 mg daily. However, given that the ever- therapy for advanced HCC. Sorafenib, a multikinase olimus half-life is significantly prolonged in patients with inhibitor that targets tyrosine kinase receptors, including impaired liver function compared with healthy volun- the vascular endothelial growth factor receptor (VEGFR), teers,20 everolimus 10 mg/day may not be the optimal is currently the only targeted agent recommended for dose in patients with HCC. The primary objective of this the treatment of patients with advanced HCC.5, 6 randomised, phase 1, dose-escalation study was to define Although sorafenib provides significant clinical benefit the maximum tolerated dose (MTD) and optimal sche- compared with no treatment, it is associated with a lim- dule of everolimus in patients with advanced HCC.
ited survival gain [overall survival (OS) 10.7 months vs.
7.9 months with placebo in the phase 3 SHARP trial and MATERIALS AND METHODS 6.5 months vs. 4.2 months with placebo in the phase 3Asia-Pacific trial], low tumour response rate (2–3% par- tial response rate) and a high incidence of diarrhoea and This was an open-label, parallel-group, noncomparative, hand-foot skin reaction.8, 9 randomised phase 1 study of daily vs. weekly schedules Mammalian target of rapamycin (mTOR) is a key of everolimus (Afinitor; Novartis Pharma AG, Basel, protein kinase that regulates cell growth, proliferation, Switzerland) for patients with advanced HCC conducted metabolism and angiogenesis.10 Upregulation of mTOR at National Cheng Kung University Hospital and Tri- signalling has been observed in 40–45% of patients with Service General Hospital in Taiwan (ClinicalTrials.gov HCC,11, 12 and in HepG2 cells, elevated levels of phos- identifier NCT00390195). A standard 3 9 3 dose-escala- phorylated mTOR were correlated with increased prolif- tion design was used. Permuted block randomisation eration.13 Preclinical studies showed that inhibition of with a block size of 6 was used to assign eligible patients mTOR with rapamycin not only reduced HepG2 prolif- to either daily or weekly everolimus. Randomisation was eration, but also inhibited tumour growth and metastasis performed at the Bio-statistical Center of Taiwan Co- and improved survival in mouse and rat models of HCC operative Oncology Group (TCOG) under the direction via both antitumour and anti-angiogenic effects.13–15 of one of the authors (CF Hsiao). The planned everoli- Everolimus, an oral mTOR inhibitor, also has been shown mus doses were 2.5, 5.0, 7.5 and 10 mg for the daily to decrease HCC cell viability in vitro and to inhibit the schedule and 20, 30, 50 and 70 mg for the weekly sche- growth of both cell line-derived and patient tissue- dule. Dose-limiting toxicities (DLTs) were defined as any derived HCC tumours in murine xenograft models.16, 17 nonhaematological toxicity of grade  3 excluding nau- Clinically, mTOR inhibitor-based immunosuppression sea, vomiting and alopecia; grade 4 neutropenia lasting has been shown to reduce the risks of HCC recurrence >7 days; neutropenic fever; or grade 4 thrombocytopenia.
Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd H.-S. Shiah et al.
Enrolment was initiated at the lowest dose level. In the and laboratory tests, including serum levels of albumin/ absence of a DLT, the subsequent cohort of patients was globulin, aspartate transaminase, ALT, alkaline phospha- randomised to the next dose level. If one out of three tase, gamma-glutamyltranspeptidase and total/direct bili- patients developed a DLT, three additional patients were treated at the same dose level. If none of the three addi- creatinine and electrolytes; complete blood count with tional patients experienced a DLT, three patients were differential count, prothrombin time/activated partial enrolled at the next dose level. The MTD was defined as thrombin time; and urinanalysis were performed once the dose level immediately below the level at which two weekly during the first treatment cycle, once every or more patients of a dose level of up to six patients 2 weeks during the second and third treatment cycles experienced a DLT. If one or fewer patients experienced and once per treatment cycle thereafter. The serum level a DLT at the last dose level of either dosing schedule, of AFP was assessed at baseline and every 4 weeks dur- the last dose level was considered to be the MTD.
ing treatment. Prophylactic anti-HBV nucleoside/nucleo- This study was approved by the institutional review tide therapy and periodic monitoring of serum levels of boards of the participating institutions and the Depart- HBV DNA were not specifically recommended in the ment of Health, Executive Yuan, Taiwan.
study protocol because the risk of HBV reactivation wasnot fully appreciated before study initiation.
Chest X-rays and computed tomography of the abdo- Eligible patients were 20–75 years of age with locally men were performed before treatment and repeated advanced or metastatic HCC that was measurable and every 8 weeks thereafter or whenever clinically indicated.
progressed after or was too advanced for definitive local Additional imaging was performed 4 weeks after the first therapy (i.e. surgical resection, radiofrequency ablation, radiological evidence of tumour response, as determined percutaneous ethanol or acetic acid injection) or trans- by an independent radiologist blinded to treatment catheter arterial chemoembolisation. The HCC diagnosis assignment, according to the Response Evaluation Crite- had to be established by cytology or histopathology or, ria in Solid Tumors (RECIST).21 in patients with cirrhosis of the liver or chronic HBV or Adverse events (AEs) were collected throughout the HCV infection, characteristic radiographic findings with study and graded according to the National Cancer Insti- a-fetoprotein (AFP)  400 ng/mL. Additional eligibility tute Common Toxicity Criteria, Version 3.0. Because the criteria included an Eastern Cooperative Oncology baseline ALT level could be as high as 2.5 9 ULN and Group (ECOG) performance score  2; Child-Pugh ALT fluctuation is common in patients with HCC, the score  9; serum levels of total bilirubin  2.0 mg/dL, grading of ALT toxicity was modified based on the abso- alanine transaminase (ALT)  2.5 times the upper limit lute ALT increase above baseline: absolute increase of of normal (ULN) and creatinine  2.0 9 ULN; white  100 IU/mL = grade 1, 101–200 IU/mL = grade 2,  3000/μL; and platelet count 201–800 IU/mL = grade 3 and  801 IU/mL = grade 4.
 50 000/μL. Prior chemotherapy or targeted therapy To determine whether the baseline serum HBV DNA were allowed but had to be completed  4 weeks before level was associated with the occurrence of grade 3/4 study entry. Other exclusion criteria included the pres- ALT elevations in hepatitis B surface antigen (HBsAg)- ence of uncontrolled inter-current illness, a history of seropositive patients, a reverse transcriptase-polymerase other malignancies within 3 years of study entry, previ- chain reaction (RT-PCR) assay (COBAS TaqMan; Roche ous therapy with a rapamycin analogue or use of inhibi- Diagnostics, Laval, Quebec, Canada) was used for post tors or inducers of P-glycoprotein, CYP3A4 or CYP3A5 hoc quantification of the HBV DNA level in stored within 2 weeks of study initiation. All patients provided serum samples.22 The lower limit of detection was written informed consent.
Therapy and clinical assessments Pharmacokinetic and pharmacogenetic studies Everolimus was given at the specified dose and schedule Blood samples for pharmacokinetic analysis in the daily in continuous 4-week cycles until disease progression, schedule were collected predose on days 1, 27, 28 and 29 unacceptable toxicity, patient refusal, withdrawal of and 1, 1.5, 2, 2.5, 3, 4, 6, 8, 12 and 24 h postdose on informed consent or death. For patients who experienced days 1 and 29. For the weekly schedule, blood samples a DLT or significant toxicity, dose reduction was allowed were collected predose at weeks 1, 3, 4 and 5 and 1, 2, 3, for subsequent treatment cycles. Physical examination 4, 6, 8, 12, 24, 72 and 168 h postdose at weeks 1 and 5.
Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd Randomised clinical trial: phase 1 study of everolimus for advanced HCC A predose 5-mL blood sample was drawn into an antico- gression-free survival (PFS) and OS were performed to agulant-free collection tube to yield 2 mL of serum for compare the efficacy of the daily and weekly dosing protein binding measurements. At the remaining time schedules. All patients were evaluated for efficacy and points, 2 mL of EDTA-containing blood were obtained.
safety (intent to treat principle). The Chi-squared test Samples were transferred to polypropylene tubes and fro- and Fisher exact test were used to compare descriptive 70°C until analysis. Levels of everolimus were variables, and the Wilcoxon Mann–Whitney approach determined using a fluorescent polarisation immunoassay was used to compare continuous variables. Any P-value (INNOFLUOR CERTICAN assay system; Seradyn, Inc., <0.05 (two-sided test) was considered statistically signifi- Indianapolis, IN, USA) based on the competitive binding principle. The pharmacokinetic parameters of area underthe time–concentration curve from time 0 to time t Role of the funding source (AUC0 t) and from time 0 to infinity (AUC0 ∞), the This was an investigator-initiated study. Novartis Phar- maximum (Cmax), minimum (Cmin) and average (Cave, maceuticals provided study drug and funding support, AUC/dosing interval) plasma concentration at steady and grant support was provided by the Department of state, elimination half-life (t1/2) and time to maximum Health, Executive Yuan, Taiwan (DOH99-TD-C-111- plasma concentration (Tmax) were determined using non- 004). All the randomisation and data analyses were pro- cessed in the TCOG under the supervision of one of the Genomic DNA was prepared from peripheral mono- authors (C.-F. Hsiao). The corresponding authors have nuclear cells obtained from 5-mL EDTA-containing full access to all the data in the study and have final blood samples. PCR products of genomic DNA were responsibility for the decision of submission for publica- subjected to direct sequencing to study polymorphisms of P-glycoprotein (MDR1) and CYP3A4 and CYP3A5alleles. The pharmacogenetic results were correlated with the pharmacokinetic parameters.
Recruitment and demography of participants Between 7 December 2006 and 2 February 2009, 39 The primary study endpoint was the MTD of the daily patients were enrolled in the study and randomly allo- and weekly schedules of everolimus. The secondary end- cated to the daily (n = 21) and weekly (n = 18) dose points were DLTs, objective tumour response per RE- schedules (Figure 1). All patients received their allocated CIST, everolimus pharmacokinetics and correlation with dose and were eligible for analysis of the MTD. At the pharmacogenetics and safety. Post hoc analyses of pro- time of analysis (3 September 2009), all but two patients Patients enrolled and randomly assigned to treatment (N = 39) Daily cohort (n = 21) Weekly cohort (n = 18) • 2.5 mg (n = 6); DLT in 1 • 20 mg (n = 3) • 5.0 mg (n = 6); DLT in 1 • 30 mg (n = 6); DLT in 1 • 7.5 mg (n = 6); DLT in 1 • 50 mg (n = 3) • 10 mg (n = 6); DLT in 2 • 70 mg (n = 6); DLT in 1 On treatment at cut-off (n = 2) On treatment at cut-off (n = 0) Discontinued (n = 19) Discontinued (n = 18) • Disease progression (n = 15) • Disease progression (n = 16) • Adverse events (n = 3) • Adverse events (n = 1) Figure 1 Study profile.
• Consent withdrawal (n = 1) • Poor adherence (n = 1) Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd H.-S. Shiah et al.
discontinued treatment, most commonly due to disease gression during the study. The progression of one of the progression (n = 15 in the daily schedule and n = 16 in patients with HBV was thought to be due to HCC pro- the weekly schedule). Demographic and baseline disease gression, not everolimus treatment. The other two cases characteristics were generally consistent between the two occurred during everolimus treatment.
schedules, except that all five patients with decompensat- Grade 3/4 ALT elevation occurred in two patients in ing liver function (Child-Pugh class B) were assigned to the weekly schedule and three patients in the daily sche- the daily schedule (Table 1). All patients had Barcelona dule. Among these five patients, one was anti-HCV sero- Clinic Liver Cancer (BCLC) stage C disease. Thirty-four positive and four were HBsAg seropositive. Although not patients (87.2%) had failed prior therapies, including 15 prespecified in the protocol, HBV and HCV viral loads (38.5%) who failed prior chemotherapy or targeted ther- were measured when ALT reached  200 IU/mL during apy. Seropositivity for HBsAg and the anti-HCV anti- everolimus treatment. In the patient seropositive for body were observed in 27 (69.2%) patients and 15 anti-HCV, the ALT increase was not associated with a (38.5%) patients respectively. Only one HBsAg-seroposi- concurrent elevation of the HCV RNA level. In the four tive patient used anti-viral therapy at study entry.
accompanied by a >1-log increase in the serum HBV Dose-limiting toxicities and maximum tolerated dose DNA level and were considered to be episodes of HBV In the daily everolimus schedule, DLTs were observed in flare. The median peak level of serum ALT in these four one patient each enrolled at the 2.5-, 5- and 7.5-mg dose patients was 470 IU/mL (range: 255–656 IU/mL). Only levels and two patients in the 10-mg dose level (Fig- one patient was symptomatic (grade 3 hyperbilirubina- ure 1). The DLTs included grade 3 diarrhoea (n = 3), emia). HBV reactivation during everolimus treatment grade 3 bilirubin elevation (n = 1) and grade 4 thrombo- occurred within 4–6 weeks in two patients and within cytopenia (n = 1). Given the occurrence of DLTs in two 12–16 weeks in two patients (Figure 2). In all four patients at the 10-mg/day dose level, the MTD for daily HBsAg-seropositive patients, everolimus was withheld everolimus dosing was determined to be 7.5 mg. DLTs and lamivudine 100 mg/day was initiated upon the were reported by one patient each enrolled at the weekly detection of HBV reactivation. Within 4–8 weeks of lam- 30- and 70-mg dose levels (grade 3 ALT elevation and ivudine initiation, the HBV DNA level declined and the grade 3 infection, n = 1 each) (Figure 1). The MTD for ALT level returned to baseline. Two patients (cases #26 weekly everolimus dosing was determined to be 70 mg, and #29) experienced radiographically confirmed disease the maximum dose assessed in this study.
progression within one month of withholding everolimusand were removed from the study. The other two Toxicity profiles patients (cases #9 and #38) received lamivudine and The median duration of everolimus exposure was everolimus concurrently until disease progression with- 16 weeks (range: 2.7 36.0 weeks) in the daily everolimus out any further episodes of HBV reactivation.
schedule and 12 weeks (range: 4.4 57.2 weeks) in theweekly everolimus schedule. AEs and laboratory abnor- Pharmacokinetics and pharmacogenetics malities led to dose reductions in nine patients (23.7%) After a single everolimus dose given on day 1 of cycle 1, and dose interruptions in 16 patients (41.0%). Across all a linear correlation between the everolimus dose and dose levels in both schedules, the most common treat- AUC0 24 was observed over the full dose range (Spear- ment-related AEs were myelosuppression, hypophosphat- man's r = 0.937; P < 0.0001). Because of rapid disease aemia, hyperglycaemia, proteinuria, ALT elevation, skin progression, two patients discontinued the study after rash, mucositis, anorexia and fatigue (Table 2). In both 4 weeks of treatment, leaving 37 patients who were avail- the daily and weekly schedules, most AEs were of grade able for pharmacokinetic analysis at week 5 (day 29).
1 or 2 severity and manageable at a dose at or below the The steady state pharmacokinetic parameters on day 29 MTD. At both the daily and weekly MTDs, grade 3/4 are listed in Table 3. Cmax, Cmin and AUC0 24 increased in an approximately dose-proportional manner over the observed in 33% of patients each; grade 3/4 diarrhoea, full dose range in the daily cohort, whereas the increases hyperglycaemia, hyponatraemia and proteinuria occurred in serum concentration and AUC0 72 were less than in 17–33% of patients in the daily MTD schedule, but in dose proportional in the weekly cohort (Figure S1). The no patients in the weekly schedule. Three patients, two concentrations of 168-h samples in the weekly cohort with HBV and one with HCV, experienced cirrhotic pro- were below the lower level of quantitation limits. The Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd Randomised clinical trial: phase 1 study of everolimus for advanced HCC Table 1 Demographic and baseline disease characteristics Daily cohort (n = 21) Weekly cohort (n = 18) All patients (N = 39) Age, years, median (range) Seropositivity, n (%) Child-pugh class, n (%) Serum a–fetoprotein level, n (%) Baseline laboratory values, median (range) Total bilirubin, μmol/L 12.0 (5.1–34.2) 12.0 (6.8–30.8) 12.0 (5.1–34.2) 1.10 (0.88–1.40) 1.12 (0.94–1.29) 1.10 (0.88–1.40) Creatinine, μmol/L 70.7 (35.4–123.8) 79.6 (44.2–123.8) 70.7 (35.4–123.8) Major vascular invasion, n (%) Modified TNM stage,43 n (%) Okuda stage, n (%) CLIP score, n (%) BCLC stage, n (%) Prior treatment, n (%) Systemic chemotherapy Molecular targeting agents ALT, alanine transaminase; Anti-HCV, anti-hepatitis C virus antibody; BCLC, Barcelona Clinic Liver Cancer; CLIP, Cancer Liver Ital-ian Program; ECOG PS, Eastern Cooperative Oncology Group performance status; INR, international normalised ratio; HBsAg,hepatitis B virus surface antigen; TNM, tumour-node-metastasis; RFA/PEI, radiofrequency ablation/percutaneous ethanol injec-tion; TACE, transcatheter arterial chemoembolisation.
Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd H.-S. Shiah et al.
Table 2 Drug-related adverse events in the daily and weekly dosing schedules Alanine transaminase* Interstitial pneumonitis All data are presented as percentage of patients.
* Because patients with baseline alanine transferase <2.5-times upper limit of normal were eligible for the study, the grading ofalanine aminotransferase (ALT) toxicity was modified based on the absolute ALT increase above baseline: absolute increase of  100 IU/mL = grade 1, 101–200 IU/mL = grade 2, 201–800 IU/mL = grade 3 and  801 IU/mL = grade 4.
24-h and 168-h AUC curves at week 5 were used to cal- culate the apparent oral clearance (CL/F) of everolimus response + stable disease) was 71.4% in the daily sche- in the daily and weekly schedules respectively. Everoli- dule [n = 15; 95% confidence interval (CI), 52.1–90.7%] mus CL/F was not affected by dose in the daily schedule, and 444% in the weekly schedule (n = 8; 95% CI, 21.4– but showed a decreasing trend over the 20- to 50-mg 67.4%). Overall, a >30% reduction in serum AFP was weekly doses (Table 3). The CL/F showed no association observed in 10 of 27 patients (37.0%) with a baseline with CYP3AP1*3 and ABCB1 genotypes among tested  200 ng/mL, including 5 of 16 individuals. Among the 12 patients who received everoli- patients (31.2%) in the daily schedule and 5 of 11 mus 2.5 mg/day or 5.0 mg/day, the CL/F in patients of patients (45.4%) in the weekly schedule. Eight of the 10 Child-Pugh class A (n = 7) and B (n = 5) were patients (80.0%) who experienced a >30% reduction in 7372.88 ± 5050.84 mL/h 4047.24 ± 727.22 mL/h AFP had a best tumour response of partial response or respectively (P = 0.18; Student t-test, two-sided).
stable disease. Waterfall plots of change in tumour sizeat best response and change in serum AFP level after 2 Response and survival cycles of treatment are shown in Figure S2. Overall med- The best overall tumour response as determined by inde- ian PFS was 16.0 weeks (95% CI: 11.0 21.0 weeks) in pendent radiologist review in the total population (N = 39) was partial response in one patient (2.6%; ever- 0 19.5 weeks) in the weekly schedule (Figure 3a). Med- olimus dose, 20 mg/week), stable disease in 22 patients ian OS was 33.4 weeks (95% CI: 9.2 57.6 weeks) and (56.4%) and progressive disease in 16 patients (41.0%; 24.6 weeks (95% CI: 0 53.5 weeks) in the daily and includes 1 patient whose response was non-evaluable).
weekly schedules respectively (Figure 3b).
Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd Randomised clinical trial: phase 1 study of everolimus for advanced HCC Case 9, 2.5 mg/day Case 26, 7.5 mg/day HBV DNA titre, IU/mL HBV DNA titre, IU/mL Weeks after everolimus treatment Weeks after everolimus treatment Case 29, 70 mg/week Case 38, 7.5 mg/day HBV DNA titre, IU/mL HBV DNA titre, IU/mL Weeks after everolimus treatment Weeks after everolimus treatment Figure 2 Changes in alanine transaminase (ALT) and hepatitis B virus (HBV) DNA level in HBsAg-seropositivepatients with grade 3/4 elevation of ALT. For each panel, the case number and everolimus dose are shown. Thechanges in ALT are represented by a line graph, the changes in HBV DNA level as a bar graph. Arrows indicate thetime point of starting lamivudine and withholding everolimus.
stage C disease (100% vs. 93%) and a Cancer of the Liver In the current study, we defined the MTD of everolimus Italian Program (CLIP) score of 4–5 (17.9% vs. 0%).
in patients with advanced HCC to be 7.5 mg daily or The most common treatment-related AEs observed in 70 mg weekly and provide clinical evidence that everoli- the present study were haematological toxicities, mucosi- mus may induce HBV reactivation and hepatitis flare in tis, skin rash, diarrhoea, fatigue, anorexia and laboratory nontransplanted patients. Of note, the optimal dose of abnormalities. This AE profile is largely consistent with everolimus in the present population of patients with the AE profile observed for everolimus in the study by advanced HCC is 7.5 mg/day, which is lower than the Zhu et al.,26 as well as the AE profiles observed in other 10-mg/day dose identified in patients with other solid studies of everolimus for patients with advanced solid malignancies23–25 and in the phase 1/2 study of patients tumours,23–25 including renal cell carcinoma,27 pancreatic with advanced HCC performed by Zhu et al.26 The lower neuroendocrine tumours28 and hormone receptor-posi- optimal dose of everolimus identified in the present study tive breast cancer.29 Most of the AEs were of grade 1 or 2 compared with the study by Zhu et al. is likely a reflec- severity and manageable. However, grade 3/4 AEs were tion of the fact that patients in this study had more more common in our daily schedule than in the other advanced disease than patients in the study by Zhu et al.
phase 1 studies of everolimus. Of note, the frequencies of More patients in the present study had an ECOG perfor- clinically relevant grade 3/4 thrombocytopenia (26.7%), mance status of 1 (76.9% vs. 57.1%) or 2 (20.5% vs.
diarrhoea (20.0%), anaemia (13.3%) and ALT elevation 3.6%), HBsAg seropositivity (57.1% vs. 17.9%), BCLC (13.3%) in the 15 patients in the present study who Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd H.-S. Shiah et al.
Table 3 Steady state pharmacokinetic parameters of everolimus 10625.6 ± 1942.0 31329.4 ± 6022.2 18101.3 ± 9037.1 AUC, area under the curve; Cmax, maximum concentration; Cmin, minimum concentration; t1/2, half-life; Tmax, time to maximum concentration.
All data are presented as mean ± standard deviation.
* AUC0 24 for daily schedule and AUC0 168 for weekly schedule.
received everolimus 5–10 mg/day were higher than those or immunotherapy, most HBV hepatitis flares occur dur- observed in the studies by O'Donnell et al. (n = 37), Tab- ing drug holidays or even weeks or months after therapy ernero et al. (n = 24) and Okamoto et al. (n = 6).23–25 is completed32; thus, it is likely that these events are The high incidence of such significant AEs in our popula- caused by rebounded cytotoxic T cells attacking hepato- tion of patients with advanced HCC is likely a result of cytes with enhanced HBsAg expression, thereby causing underlying chronic liver diseases and related complica- liver parenchyma damage. Conversely, all the grade 3/4 tions, the altered pharmacokinetics of everolimus in ALT elevations in our HBsAg-seropositive patients patients with hepatic insufficiency or a combination of occurred during everolimus treatment, including three the two. These factors may also limit the ability to com- patients receiving continuous daily dosing of everolimus bine everolimus with other targeted therapies. For exam- and one patient on the weekly schedule. In two in vitro ple, the phase 2 portion of a study of everolimus plus studies, Guo et al. and Teng et al. demonstrated that sorafenib for untreated advanced HCC (ClinicalTrials.gov inhibition of the phosphatidylinositol 3-kinase/Akt/ identifier NCT00828594) was not conducted due to the mTOR-signaling pathway could enhance the transcrip- toxicity observed in the phase 1 dose-finding portion of tion of HBV RNA in HBV-expressing HepG2.2.15 cells34 the study30 despite the fact that preclinical studies sug- and the expression of HBV surface protein in Huh-7 gested antitumour synergism between these two thera- cells.35 Given the immunosuppressive nature of everoli- pies.31 Therefore, the partner for everolimus in clinical mus, we speculate that the observed everolimus-induced studies of combination therapy for advanced HCC should HBV hepatitis flare may represent early-stage fibrosing be carefully selected to maximise antitumour synergism cholestatic or cytolytic hepatitis, in which the hepatocell- and minimise the overlap of the safety profiles.
uar damage is caused by cytopathic effects of highly In the present study, grade 3/4 ALT elevations that expressed HBV proteins or vial particles within hepato- occurred in 4 HBsAg-seropositive patients were accom- cytes of immunocompromised patients36–39 and detected panied by >1-log increases of serum HBV DNA levels by the rigorous liver function monitoring mandated as and considered to be episodes of HBV hepatitis flare.
part of the clinical trial. In contrast with the majority of HBV hepatitis flare is not an uncommon AE in HBV HBV-related fibrosing cholestatic hepatitis observed in carriers receiving systemic chemotherapy or immunosup- post-transplant patients, which is frequently diagnosed at pressant therapy.32 Because everolimus is known to have a late stage and associated with fatal outcomes,40 all events immunosuppressive properties, we were surprised to observed in this study resolved within 4–8 weeks of with- note after an extensive literature review that there are holding everolimus and the concomitant administration of very few other reports of everolimus-associated HBV anti-HBV nucleotide/nucleoside therapy. Post hoc analy- hepatitis flare28, 33 and that this appears to be the first sis showed the incidence of hepatitis flare in the present detailed report of clinically relevant everolimus-associ- study to be significantly higher in HBsAg-seropositive ated HBV hepatitis flare. In recipients of chemotherapy patients with detectable baseline serum HBV DNA levels Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd Randomised clinical trial: phase 1 study of everolimus for advanced HCC weekly dosing schedules. Our data show that the steady state CL/F of everolimus in patients with HCC was lower than that observed in non-HCC patients, whereas the t1/2, Cmax and AUC0 24 were higher.23–25 These findings con-cur with a study reported by Kovarik et al., which com- pared the pharmacokinetics of a single 2-mg dose ofeverolimus in healthy subjects and patients with hepaticimpairment (Child-Pugh B)20 and suggest that the oral clearance of everolimus is significantly reduced in patientswith hepatic dysfunction. Although in the present study there was no significant difference in everolimus CL/F in Probability of cumulative survival the patients with Child-Pugh A (n = 7) and B (n = 5) who received everolimus 2.5–5.0 mg/day, the analysis may be underpowered by the limited number of patients. The Time after treatment (weeks) true impact of Child-Pugh stage on the pharmacokineticsof everolimus 7.5 mg/day in patients with advanced HCC will be further evaluated in an ongoing phase 2 trial (Clini- calTrials.gov identifier NCT00390195).
Efficacy data from this study show that everolimus is moderately active in stabilising the progression of advancedHCC. Although this study was not designed to compare the efficacy of the daily and weekly dosing schedules, thedisease control rate was higher in the daily vs. weekly sche- dule (71.4% vs. 44.4%), and median PFS [16.0 weeks(3.7 months) [33.4 weeks (7.7 months) vs. 24.6 weeks (5.7 months)] were Probability of cumulative survival longer. The median PFS and OS observed in the daily sche- dule of the present study were nearly identical to thosereported in a phase 1/2 study of everolimus for advanced HCC (3.8 months and 8.4 months, respectively)26 and Time after treatment (weeks) longer than the median time to progression (3.0 months)and OS (5.3–6.5 months) observed in small studies of rapa- Figure 3 Kaplan–Meier estimates of progression-free and overall survival. (a) Daily dosing cohort.
mycin for advanced HCC.41, 42 Of note, the median OS (b) Weekly dosing cohort.
observed for the daily schedule in the present study(7.7 months) was longer than the median OS observed forsorafenib- and placebo-treated patients in the phase 3 Asia- (46.2% vs. 7.1% of patients without detectable HBV Pacific study of sorafenib for advanced HCC (6.5 months DNA at baseline; P < 0.01, Fisher exact test). Based on and 4.2 months, respectively).9 In comparison with the pre- our findings, prophylactic anti-HBV therapy and close sent study, the median OS in the phase 3 SHARP study was monitoring of HBV DNA and ALT levels during treat- longer for sorafenib-treated patients (10.7 months) and ment should be mandatory for HBsAg-seropositive similar for placebo-treated patients (7.9 months).8 However, patients who receive everolimus. In the phase 1/2 study comparison with the Asia-Pacific trial is likely more relevant of everolimus for advanced HCC conducted by Zhu as this patient population is more comparable to that of the et al., all patients with HBV received anti-viral therapy, present study. Overall and considering that all patients and no HBV reactivation was observed.26 enrolled in the present study had locally advanced or In the current study, everolimus was rapidly absorbed metastatic disease and most were symptomatic (97.4% with across all dose levels, with a Tmax of 1–2 h. Similar to what ECOG performance status 1–2) and heavily pre-treated, was observed in other studies of everolimus for patients including 23.1% and 30.8% who received prior systemic che- with solid malignancies,23–25 steady state Cmax, Cmin and motherapy and molecularly targeted therapy respectively, AUC0 t were largely dose-dependent in both the daily and the observed clinical activity is encouraging.
Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd H.-S. Shiah et al.
In conclusion, the results of the present study identi- Research Institutes). This investigator-initiated study was fied the daily and weekly MTDs of everolimus for sponsored by Novartis Pharma AG, Basel, Switzerland, patients with advanced HCC to be 7.5 mg and 70 mg with administration and personnel support from the respectively. At these doses, everolimus demonstrated National Institute of Cancer Research, National Health acceptable tolerability and preliminary evidence of clini- Research Institutes, Taiwan (DOH99-TD-C-111-004).
cal activity. Because patients in the daily schedule had a Declaration of personal interests: J. Whang-Peng: higher disease control rate and longer median PFS and received honoraria for scientific presentations from OS than patients in the weekly schedule, everolimus Novartis Pharmaceuticals. L.-T. Chen has served as an 7.5 mg daily is recommended for future studies con- consultant and advisory board member, received honor- ducted in advanced HCC. Based on the HBV flare aria for scientific presentations and research funding from observed in HBsAg-seropositive patients, prophylactic anti-viral therapy and close monitoring of HBV DNA Declaration of funding interests: This investigator-initi- and ALT levels should be mandatory for HBsAg- ated study received funding and free everolimus samples seropositive patients who receive everolimus. The effi- from Novartis Pharmaceuticals and personnel support cacy and safety of everolimus 7.5 mg daily is being from the Department of Health, Executive Yuan, Taiwan compared with that of placebo, both given with best (DOH99-TD-C-111-004). Initial data analyses were undertaken by the Biostatistical Center, Taiwan Coopera- that progressed after sorafenib or who are sorafenib tive Oncology Group, National Institue of Cancer intolerant in the ongoing international, randomised, Research. Editorial support was provided by Melanie phase 3 EVOLVE-1 trial (ClinicalTrials.gov identifier Leiby of ApotheCom (Yardley, PA, USA) and funded by SUPPORTING INFORMATION Guarantor of the article: L.-T. Chen.
Additional Supporting Information may be found in the Author contributions: All authors participated in the online version of this article: design of the study and contributed to the writing of the Figure S1. Steady state pharmacokinetic parameters manuscript. H.-S. Shiah, C.-Y. Chen, Y.-J. Lin, W.-C. Su, on day 29 by everolimus dose. (a) Cmax, steady state J.-Y. Chang, J. Whang-Peng, P.-W. Lin and L.-T. Chen maximum serum concentration. (b) Cmin, steady state participated in the collection and analysis of data from minimum serum concentration. (c) AUC0 t, area under the patient records. C.-Y. Dai participated in the analysis the curve within 24 h for the daily schedule and 168 h of the hepatitis virus data. C.-F. Hsiao participated in for the weekly schedule. (d) Oral clearance. Each circle analysis of the biostatistics. J.-D. Huang participated in represents data from an individual patient.
the analysis of pharmacokinetics. All authors have Figure S2. Clinical outcomes with daily and weekly approved the final version of the article, including the everolimus dosing. Waterfall plots of best percentage authorship list.
change from baseline with (a) daily and (b) weekly ever-olimus dosing. Change of alpha-fetoprotein (AFP) level after 8 weeks of (c) daily and (d) weekly everolimus dos- We would like to express our sincere thanks to the ing in patients whose baseline AFP level was >200 ng/ patients and families who participated in this study and mL. *Denotes patients with AFP greater than 45 000 the research nurses who contributed to this study: Ms.
ng/mL both before and after treatment so that the Tsai-Rong Chung and Hsiao-Wei Wu (National Heath percentage of change cannot be estimated.
1. Ferlay J, Shin HR, Bray F, Forman D, carcinogenesis. Gastroenterology 2007; management of hepatocellular Mathers C, Parkin DM. Estimates of 132: 2557–76.
carcinoma–an updated analysis of worldwide burden of cancer in 2008: 3. Forner A, Llovet JM, Bruix J.
randomized controlled trials. Aliment GLOBOCAN 2008. Int J Cancer 2010; Hepatocellular carcinoma. Lancet 2012; Pharmacol Ther 2006; 23: 1535–47.
127: 2893–917.
379: 1245–55.
5. National Comprehensive Cancer 2. El-Serag HB, Rudolph KL. Hepatocellular 4. Lopez PM, Villanueva A, Llovet JM.
Network, Inc. NCCN Clinical Practice carcinoma: epidemiology and molecular Systematic review: evidence-based Guidelines in Oncology: Hepatobiliary Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd Randomised clinical trial: phase 1 study of everolimus for advanced HCC Cancers. Version 2.2012. 2012.
of the International Liver Cancer Available at: http://www.nccn.org/ Gastroenterology 2008; 135: 1972–83.
Association, 2–4 Sep 2011.
18. Zaghla H, Selby RR, Chan LS, et al. A 31. Piguet AC, Saar B, Hlushchuk R, et al.
hepatobiliary.pdf. Accessed April 16, comparison of sirolimus vs. calcineurin Everolimus augments the effects of sorafenib in a syngeneic orthotopic 6. European Association for the Study of therapies in liver transplantation. Aliment model of hepatocellular carcinoma.
the Liver; European Organisation for Pharmacol Ther 2006; 23: 513–20.
Mol Cancer Ther 2011; 10: 1007–17.
Research and Treatment of Cancer.
19. Liang W, Wang D, Ling X, et al.
32. Hoofnagle JH. Reactivation of hepatitis EASL-EORTC Clinical Practice Sirolimus-based immunosuppression in B. Hepatology 2009; 49: S156–65.
Guidelines: management of liver transplantation for hepatocellular 33. Stypmann J, Engelen MA, hepatocellular carcinoma. Eur J Cancer carcinoma: a meta-analysis. Liver Eckernkemper S, et al. Calcineurin 2012; 48: 599–641.
Transpl 2012; 18: 62–9.
inhibitor-free immunosuppression using 7. Kanwal F, Befeler A, Chari RS, et al.
20. Kovarik JM, Sabia HD, Figueiredo J, everolimus (Certican) after heart Potentially curative treatment in et al. Influence of hepatic impairment transplantation: 2 years' follow-up from patients with hepatocellular cancer– on everolimus pharmacokinetics: the University Hospital Munster.
results from the liver cancer research implications for dose adjustment. Clin Transplant Proc 2011; 43: 1847–52.
network. Aliment Pharmacol Ther 2012; Pharmacol Ther 2001; 70: 425–30.
34. Guo H, Zhou T, Jiang D, et al.
36: 257–65.
21. Therasse P, Arbuck SG, Eisenhauer EA, Regulation of hepatitis B virus 8. Llovet JM, Ricci S, Mazzaferro V, et al.
et al. New guidelines to evaluate the replication by the phosphatidylinositol Sorafenib in advanced hepatocellular response to treatment in solid tumors. J 3-kinase-akt signal transduction carcinoma. N Engl J Med 2008; 359: Natl Cancer Inst 2000; 92: 205–16.
pathway. J Virol 2007; 81: 10072–80.
22. Liu SF, Hsieh MH, Hou NJ, et al.
35. Teng CF, Wu HC, Tsai HW, Shiah HS, 9. Cheng AL, Kang YK, Chen Z, et al.
Hepatitis B virus genotyping by Huang W, Su IJ. Novel feedback Efficacy and safety of sorafenib in enzyme-linked immunosorbent assay in inhibition of surface antigen synthesis by patients in the Asia-Pacific region with Taiwan. Hepatol Int 2010; 4: 601–7.
mammalian target of rapamycin advanced hepatocellular carcinoma: a 23. O'Donnell A, Faivre S, Burris HA III, (mTOR) signal and its implication for phase III randomised, double-blind, et al. Phase I pharmacokinetic and hepatitis B virus tumorigenesis and placebo-controlled trial. Lancet Oncol pharmacodynamic study of the oral therapy. Hepatology 2011; 54: 1199–207.
2009; 10: 25–34.
mammalian target of rapamycin 36. Davies SE, Portmann BC, O'Grady JG, 10. Shaw RJ, Cantley LC. Ras, PI(3)K and inhibitor everolimus in patients with et al. Hepatic histological findings after mTOR signalling controls tumour cell advanced solid tumors. J Clin Oncol transplantation for chronic hepatitis B growth. Nature 2006; 441: 424–30.
2008; 26: 1588–95.
virus infection, including a unique 11. Sahin F, Kannangai R, Adegbola O, 24. Okamoto I, Doi T, Ohtsu A, et al.
pattern of fibrosing cholestatic hepatitis.
Wang J, Su G, Torbenson M. mTOR Phase I clinical and pharmacokinetic Hepatology 1991; 13: 150–7.
and P70 S6 kinase expression in study of RAD001 (everolimus) 37. Benner KG, Lee RG, Keeffe EB, Lopez primary liver neoplasms. Clin Cancer administered daily to Japanese patients RR, Sasaki AW, Pinson CW. Fibrosing Res 2004; 10: 8421–5.
with advanced solid tumors. Jpn J Clin cytolytic liver failure secondary to 12. Sieghart W, Fuereder T, Schmid K, Oncol 2010; 40: 17–23.
recurrent hepatitis B after liver et al. Mammalian target of rapamycin 25. Tabernero J, Rojo F, Calvo E, et al.
transplantation. Gastroenterology 1992; pathway activity in hepatocellular Dose- and schedule-dependent 103: 1307–12.
carcinomas of patients undergoing liver inhibition of the mammalian target of 38. Lau JY, Bain VG, Davies SE, et al. High- transplantation. Transplantation 2007; rapamycin pathway with everolimus: a level expression of hepatitis B viral 83: 425–32.
phase I tumor pharmacodynamic study antigens in fibrosing cholestatic hepatitis.
13. Varma S, Khandelwal RL. Effects of in patients with advanced solid tumors.
Gastroenterology 1992; 102: 956–62.
rapamycin on cell proliferation and J Clin Oncol 2008; 26: 1603–10.
39. Meuleman P, Libbrecht L, Wieland S, et al.
phosphorylation of mTOR and p70(S6K) 26. Zhu AX, Abrams TA, Miksad R, et al.
Immune suppression uncovers endogenous in HepG2 and HepG2 cells overexpressing Phase 1/2 study of everolimus in cytopathic effects of the hepatitis B virus. J constitutively active Akt/PKB. Biochim advanced hepatocellular carcinoma.
Virol 2006; 80: 2797–807.
Biophys Acta 2007; 1770: 71–8.
Cancer 2011; 117: 5094–102.
40. Jung S, Lee HC, Han JM, et al. Four 14. Guba M, von Breitenbuch P, Steinbauer 27. Motzer RJ, Escudier B, Oudard S, et al.
cases of hepatitis B virus-related M, et al. Rapamycin inhibits primary Phase 3 trial of everolimus for fibrosing cholestatic hepatitis treated and metastatic tumor growth by metastatic renal cell carcinoma: final with lamivudine. J Gastroenterol antiangiogenesis: involvement of results and analysis of prognostic Hepatol 2002; 17: 345–50.
vascular endothelial growth factor. Nat factors. Cancer 2010; 116: 4256–65.
41. Schöniger-Hekele M, Müller C. Pilot Med 2002; 8: 128–35.
28. Yao JC, Shah MH, Ito T, et al.
study: rapamycin in advanced 15. Semela D, Piguet AC, Kolev M, et al.
Everolimus for advanced pancreatic hepatocellular carcinoma. Aliment Vascular remodeling and antitumoral neuroendocrine tumors. N Engl J Med Pharmacol Ther 2010; 32: 763–8.
effects of mTOR inhibition in a rat 2011; 364: 514–23.
42. Rizell M, Andersson M, Cahlin C, model of hepatocellular carcinoma. J 29. Baselga J, Campone M, Piccart M, et al.
Hafstrom L, Olausson M, Lindner P.
Hepatol 2007; 46: 840–8.
Everolimus in postmenopausal hormone Effects of the mTOR inhibitor sirolimus 16. Huynh H, Chow KH, Soo KC, et al.
receptor-positive advanced breast in patients with hepatocellular and RAD001 (everolimus) inhibits tumour cancer. N Engl J Med 2012; 366: 520–9.
cholangiocellular cancer. Int J Clin growth in xenograft models of human 30. Poon RTP, Finn RS, Yau T, et al.
Oncol 2008; 13: 66–70.
hepatocellular carcinoma. J Cell Mol Everolimus in combination with 43. Vauthey JN, Lauwers GY, Esnaola NF, Med 2009; 13: 1371–80.
sorafenib in patients with advanced et al. Simplified staging for 17. Villanueva A, Chiang DY, Newell P, hepatocellular carcinoma. Hong Kong: hepatocellular carcinoma. J Clin Oncol et al. Pivotal role of mTOR signaling in Presented at the 5th Annual Conference 2002; 20: 1527–36.
Aliment Pharmacol Ther 2013; 37: 62-73 ª 2012 Blackwell Publishing Ltd

Source: http://filer.case.edu/djc26/clinicaltrials/207.apt12132.pdf


The battery connector must be added to the power side of the controller (black HYDRA 120 & HYDRA 240 OPERATION MANUAL capacitors, receiver connector, and red and black wire side). The red wire is the positive (+) lead, and must match up to the positive lead from your battery. The black wire is the negative (-) lead, and must match up to the negative lead from


Dental Research Journal Original ArticleTitanium nanotubes stimulate osteoblast differentiation of stem cells from pulp and adipose tissue Alfonso Pozio1, Annalisa Palmieri2, Ambra Girardi3, Francesca Cura3, Francesco Carinci21ENEA, IDROCOMB, C.R. Casaccia, Rome, 2Department of Medical-Surgical Sciences of Communication and Behavior, Section of Maxillofacial and