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This phase I study evaluated the safety, tolerability, pharmacokinetics and preliminary efficacy of the combination of decitabine with vorinostat.
Patients with advanced solid tumors or non-Hodgkin's lymphomas were eligible. Sequential and concurrent schedules were studied.
Forty-three patients were studied in 9 different dose levels (6 sequential and 3 concurrent). The maximum tolerated dose (MTD) on the sequential schedule was decitabine 10 mg/m2/day on days 1-5 and vorinostat 200 mg three times a day on days 6-12. The MTD on the concurrent schedule was decitabine 10 mg/m2/day on days 1-5 with vorinostat 200 mg twice a day on days 3-9. However, the sequential schedule of decitabine 10 mg/m2/day on days 1-5 and vorinostat 200 mg twice a day on days 6-12 was more deliverable than both MTDs with fewer delays on repeated dosing and it represents the recommended phase II (RP2D) dose of this combination. Dose-limiting toxicities during the first cycle consisted of myelosuppression, constitutional and gastrointestinal symptoms and occurred in 12/42 (29%) patients evaluable for toxicity. The most common ≥ grade 3 adverse events were neutropenia (49% of patients), thrombocytopenia (16%), fatigue (16%), lymphopenia (14%), and febrile neutropenia (7%). Disease stabilization for ≥ 4 cycles was observed in 11/38 (29%) evaluable patients.
The combination of decitabine with vorinostat is tolerable on both concurrent schedules in previously treated patients with advanced solid tumors or non-Hodgkin's lymphomas. The sequential schedule was easier to deliver. The combination showed activity with prolonged disease stabilization in different tumor types.
Hypermethylation of cytosines in CpG dinucleotides in the promoter regions of tumor-suppression genes and deacetylation of amino acid residues on the histone tails of nucleosomes, represent two epigenetic mechanisms of gene silencing that can contribute to tumor formation and progression. (1, 2) Both events are considered reversible, and agents that inhibit the enzymes responsible for DNA methylation and histone deacetylation have been developed as anticancer agents. (3)
Decitabine (5-aza-2'-deoxycytidine), a nucleoside analogue that is incorporated into DNA and acts as an hypomethylating agent by inhibiting DNA methyltransferase, and vorinostat (suberoylanilide hydroxamic acid), a small molecule that binds and directly inhibits histone deacetylase, are two agents with epigenetic effects that have shown clinical antitumor activity and are now approved for the treatment of myelodysplastic syndrome and cutaneous T-cell lymphoma, respectively. (4-7) The validation of epigenetic treatments as anticancer strategies has supported an increasing number of trials evaluating epigenetic agents alone or in combination with other agents in both hematologic and solid malignancies. (8, 9)
The combination of DNA methyltransferase inhibitor (DNMTi) with a histone deacetylase inhibitor (HDACi) represents an area that is gaining attention in the clinical development of epigenetic therapies. This concept is supported by preclinical evidence that DNA methylation and histone deacetylation are functionally linked, leading to transcriptional inactivation of genes critical for tumorigenesis. (10, 11) Moreover, the in vitro combination of a DNMTi with an HDACi in hematologic and solid tumor cell lines have shown synergistic effects resulting in increased gene re-expression and superior antitumor activity. (12-14)
The optimal schedule of the combination of a DNMTi with an HDACi has not been established yet. Although most of the preclinical studies performed have used a sequential administration of DNMTi followed by HDACi, it remains unclear whether different schedules of administration may have better clinical activity. In the phase I trial reported here, the combination decitabine and vorinostat were studied for the first time in patients with solid tumors and non-Hodgkin's lymphomas (NHLs). Two different schedules of administration, sequential and concurrent, were evaluated. The principal objective of this study was to determine the safety and tolerability of the combination. Secondary objectives included the assessments of pharmacokinetics and preliminary antitumor efficacy.
Patients were eligible if they had a histologically or cytologically documented advanced solid malignancy or non-Hodgkin's lymphoma, refractory to standard therapy or for which no standard therapy existed. Other key eligibility criteria included: Eastern Cooperative Oncology Group performance status 0 to 2; adequate hematologic, hepatic, and renal functions (white blood cell count ≥ 3 × 109/L, absolute neutrophil count (ANC) ≥ 1.5 × 109/L, platelets ≥ 100 × 109/L, AST/ALT ≤ 2.5 times upper limit of normal, bilirubin within normal limits, creatinine ≤ 150 μmol/L and creatinine clearance ≥ 60 mL/min); unlimited prior chemotherapy, radiotherapy or targeted agents with at least 3-week interval (6-week interval if prior nitrosoureas or mitomycin C) between study entry and any prior treatment; no valproic acid or other HDACi for at least 2 weeks before study entry; no prior decitabine; and no known brain metastases.
The institutional review board of both participating centers approved the study, which was conducted in accordance with federal and institutional guidelines.
This was a two-center, open-label, phase I study in which intravenous decitabine administered on days 1-5 was combined with oral vorinostat either in a sequential (vorinostat starting on day 6) or a concurrent schedule (vorinostat starting on day 3), in 28-day cycles. The study began with dose escalation on the sequential schedule, and once the maximum tolerated dose (MTD) was established, accrual began on the concurrent schedule. On the sequential schedule, the starting dose of decitabine was 20 mg/m2/day on days 1-5, given as an intravenous infusion over 1 hour. Vorinostat was given at a starting dose of 100 mg twice a day on days 6-21. The starting dose of decitabine was chosen on the basis of published data showing good tolerability and higher response rates in patients with myelodysplastic syndrome treated with 20 mg/m2/day for 5 days. (15) The starting dose of vorinostat was based on previous monotherapy studies showing that the maximum tolerated dose was 200 mg orally twice a day continuously in patients with solid tumors and 250 mg orally thrice a day for 14 days every 21 days in patients with hematologic malignancies. (16, 17) No dose escalation or modification of the duration of treatment with decitabine were planned, while both dose escalation (up to 200 mg orally thrice a day) and evaluation of different durations of treatment (7, 16 or 21 days, starting on day 6) were initially planned for vorinostat. For the concurrent schedule, the starting doses of decitabine and vorinostat were based on the MTD established on the sequential schedule and dose escalation and evaluations of different durations of treatment (7 or 14 days, starting on day 3) were planned for vorinostat only.
Dose escalation in both schedules followed the standard 3+3 rule. The RP2D of this study was defined as the dose level at which ≤1 of 6 patients developed dose-limiting toxicity (DLT) and had the lowest frequency of treatment delays. Toxicity was graded using the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. DLTs were defined as adverse events occurring during the first cycle of treatment and fulfilling one of the following criteria: ANC < 0.5 × 109/L for ≥ 7 days, febrile neutropenia, platelets < 25 × 109/L or grade 3 thrombocytopenia associated with bleeding; any grade ≥ 3 or intolerable grade 2 non-hematologic toxicity except alopecia, nausea and vomiting responsive to anti-emetics, diarrhea responsive to medications and electrolyte abnormalities correctable with supportive therapy; and any toxicity resulting in treatment delay > 2 weeks. Response was assessed every 2 cycles using the Response Evaluation Criteria in Solid Tumors. (18)
Pretreatment evaluation consisted of a complete medical history, physical examination, vital signs, electrocardiogram, complete blood count (CBC), serum chemistries, prothrombin time/INR and activated partial thromboplastin time, serum or urine pregnancy test and baseline tumor measurements. On days 1, 8 and 15 of each cycle, evaluation consisted of a brief history and physical examination (day 1), vital signs (day 1), CBC and serum chemistries.
Patients who experienced any DLT had treatment delayed by 1-week intervals until recovery and then may have continued on study with reduction of decitabine and vorinostat by one dose level. If no recovery occurred after a delay of 3 weeks of the next scheduled treatment cycle, patients were discontinued from protocol treatment. Blood counts must be recovered to begin a new treatment cycle.
Patients with an objective response or stable disease were allowed to remain on study until disease progression. Otherwise, study treatment continued until disease progression, unacceptable adverse event, patient's decision to withdraw consent, or changes in the patient's condition that rendered the continuation of study treatment unacceptable.
Blood samples for evaluation of decitabine were collected on days 1 and 5 of cycle 1, before dosing, 30 minutes after the infusion had started, at the end of infusion and at 5, 20, 35, 45 and 60 minutes from the end of infusion. Blood was collected into a sodium heparin Vacutainer tube and centrifuged at 1500 × g for 15 min. The resulting plasma was transferred into polypropylene tubes and stored at -70 °C until analyzed for decitabine concentration using a validated high performance liquid chromatography with tandem mass spectrometry (LC-MS/MS). (19) On the sequential schedule, blood samples for vorinostat were collected on day 9 of cycle 1 before dosing and at 0.5, 1, 2, 2.5, 3, 4, 6 and 8 hours after dosing. On the concurrent schedule, blood samples were collected on day 4 of cycle 1 at the same time points. Samples were allowed to clot at 4 °C for 20-30 minutes, then centrifuged at 2000 × g for 15 min at 4 °C. The resulting serum was transferred to polypropylene cryotubes and stored at -70 °C until analyzed for vorinostat concentrations with a validated LC-MS/MS assay. (20) Pharmacokinetic parameters were calculated by non-compartmental methods using WinNonlin (Version 5.2, Pharsight Corp., Mountain View, CA)
Exploratory analyses were performed for pharmacokinetic parameters and adjustments made for multiple comparisons. T-tests were used for independent group comparisons and paired t-tests were used to compare pharmacokinetic parameters of decitabine on day 1 versus day 5 within a dose level.
Forty-four patients were enrolled into this study and 43 received treatment for a total of 136 cycles (median 2, range: 1-25) (Table 1). One patient with neuroendocrine carcinoma of the pancreas did not receive treatment because baseline CT scans showed no significant growth of disease.
All patients had progressed from previous treatments for advanced disease. The median number of prior systemic treatment lines was three. Three patients were treated previously with radiation therapy only and had not received systemic therapy.
A total of 43 patients received at least one cycle of study treatment. At the time of data cut off (March 2010), treatment was discontinued due to radiologically confirmed progression or due to symptomatic deterioration caused by underlying disease in 37 patients; five patients discontinued due to adverse events related to study treatment; one patient with stable disease after 25 cycles remains on study. There were no treatment-related deaths.
Six dose levels were evaluated on the sequential and 3 on the concurrent schedule (Figure 1). On the sequential schedule, 8 of 30 (27%) evaluable patients experienced at least one DLT. The nature of DLTs was as follows: hematologic in 5 patients, nonhematologic in 2 and both hematologic and non-hematologic in one patient. Among hematologic DLTs, grade 4 thrombocytopenia occurred in 4 patients, grade 4 neutropenia lasting ≥ 7 days occurred in 2 and febrile neutropenia occurred in 2 patients. There was a clear association between hematologic DLTs and higher doses of decitabine. In fact, among 14 patients treated at the two dose levels with decitabine given at 10 mg/m2/day, only one heavily pre-treated patient with non-Hodgkin's lymphoma who had a prior autotransplant developed a hematologic DLT, consisting of grade 4 thrombocytopenia. Regarding non-hematologic DLTs, one patient encountered grade 2 intolerable fatigue, anorexia and dehydration, one had grade 3 fatigue and one had grade 3 constipation (plus febrile neutropenia and grade 4 thrombocytopenia). Among 12 patients treated on the concurrent schedule, four (33%) developed a DLT. Three patients had non-hematologic DLTs (one grade 3 fatigue and two grade 3 fatigue and grade 3 dehydration), and one patient experienced a hematologic DLT (grade 3 febrile neutropenia).
Neutropenia and thrombocytopenia were the most frequent adverse events of at least possible attribution to study treatment (Table 2). Fatigue, nausea, diarrhea and vomiting were the most frequent non-hematologic adverse events (Table 2). Seven patients experienced > 1 episode of grade 3 fatigue while other non-hematologic adverse events were mostly grade 1 or 2.
Treatment delay due to related adverse events was calculated in patients who received ≥ 2 cycles of treatment: on the sequential schedule, a treatment delay for ≥ 1 occasion occurred in 4/4 (100%), 2/2 (100%), 2/2 (100%), 0/2 (0%), 1/5 (20%), and 3/5 (60%) patients, on dose levels 1, -1, 1a, 1b, -1b, -2b respectively. Among patients treated on the concurrent schedule, ≥ 1 treatment delay occurred in 2/6 (33%), 1/1 (100%) and 1/1 (100%) patients on dose levels -2b, -3b and -3c respectively.
Dose reductions or omissions occurred as follows: on the sequential schedule 4/6 (66%), 1/3 (33%), 2/4 (50%), 1/4 (25%), 2/7 (29%) 1/7 (14%) patients on dose levels 1, -1, 1a, 1b, -1b, -2b respectively, and on the concurrent schedule 0/7 (0%), 2/3 (66%) and 2/2 (100%) patients on dose levels -2b, -3b and -3c respectively.
Three patients treated on the sequential schedule (10%) discontinued the study due to adverse events possibly related to the treatment. These consisted of fatigue and nausea in one, nausea and neutropenia in another, and nausea and vomiting in the third. On the concurrent schedule, 2/12 (17%) patients discontinued treatment due to treatment related adverse events. One event was fatigue, while the other patient developed skin changes that were biopsied and showed a neutrophilic dermatitis consistent with Sweet syndrome, a rare syndrome that has previously been described in patients with myelodysplastic syndrome/acute leukaemia treated with the combination of HDACi and DNMTi. (21) After discontinuation of treatment and a course of oral prednisone, the skin changes resolved.
Based on the occurrence of DLTs reported above, the MTD for the sequential combination was decitabine 10 mg/m2/day on days 1-5 with vorinostat 200 mg three times a day on days 6-12. The MTD for the concurrent schedule was decitabine 10 mg/m2/day on days 1-5 with vorinostat 200 mg two times a day on days 3-9. Among the sequential schedules, the highest dose with the least treatment delay was achieved in dose level -1b (decitabine 10 mg/m2/day on days 1-5 with vorinostat 200 mg twice daily, days 6-12). This is also the dose level with the highest percentage of patients with stable disease for ≥ 4 cycles. In fact, 4 of the 11 patients (36%) who remained on study for ≥ 4 cycles were treated at this dose level. Thus, this dose level represents the RP2D for the combination of the two drugs.
No objective tumor responses were observed. Among 38 patients evaluable for response, eleven (29%) with previously progressive cancers had stable disease for ≥ 4 cycles of treatment. Three of 11 had stable disease ≥ 8 cycles including one patient with colon cancer (8 cycles), one patient with thymoma (11 cycles), and one patient with mucinous adenocarcinoma of the appendix who remains on study after 25 cycles (Figure 2).
Pharmacokinetic results of decitabine were similar to those reported in previous studies. (22) Decitabine is rapidly eliminated with a half-life of approximately 20 minutes. On the sequential schedule, increasing doses of decitabine did not produce dose proportional increases in maximum plasma concentration (Cmax) and area under the plasma concentration-time curve (AUC). No significant differences were found when comparing pharmacokinetic parameters on day 1 and day 5 within the same dose level in either schedule. Additionally, there were no statistically significant differences when comparing pharmacokinetic parameters for the dose of 10 mg/m2/day between the two schedules of administration.
A comparison of vorinostat pharmacokinetic parameters with increasing doses was possible only for the sequential schedule. AUC and Cmax after a single vorinostat administration increased proportionaly when the dose of vorinostat was increased from 100 mg to 200 mg. Interestingly, Cmax, AUCinf (= AUC to infinity) and AUCt (= AUC over dosing interval) were lower in the concurrent schedule than those in the sequential schedule (p 0.09, 0.004 and 0.0005, respectively) at the 200mg BID dose level. The difference in the AUCt remains statistically significant after adjustment for multiple comparisons (Supplementary Figure A1).
Aberrant DNA methylation and histone deacetylation are involved in tumor formation and progression and have been evaluated as targets for the development of anticancer agents. (1, 2) The possibility of optimally re-expressing methylated genes following treatment with the combination of a DNMTi with an HDACi has been confirmed in preclinical studies and formed the basis for clinical trials using combined epigenetic therapies. (23)
Here we report for the first time the results of a phase I trial demonstrating the feasibility of delivering decitabine in combination with vorinostat in patients with advanced solid tumors or non-Hodgkin's lymphomas. Decitabine given for 5 days at a dose of 10 mg/m2/day as a 1-hour intravenous infusion can be combined with oral vorinostat either on a sequential (vorinostat 200 mg three times a day on days 6-12) or a concurrent schedule (vorinostat 200 mg two times a day on days 3-9). The toxicities observed were predictable and manageable at these stated MTD doses. In both schedules, the combination of decitabine and vorinostat appears to have a narrow therapeutic index and both drugs required dose reductions from their single-agent recommended doses used in previous studies of hematologic malignancies and solid tumors. However, the optimal single-agent doses of decitabine and vorinostat in patients with solid tumors remain unknown and there is no clear evidence that higher doses are associated with better outcome.
Among the two schedules evaluated in this study, the sequential schedule appears to be easier to deliver and more tolerable. Additionally, pharmacokinetic analyses showed that for the same dose of vorinostat, AUC and Cmax were lower for the concurrent schedule suggesting a possible unfavorable pharmacokinetic interaction between the two drugs. However the number of patients enrolled in our study was small and the study was not designed to establish if this was due to increased metabolism or reduced absorption of vorinostat. Notably, escalation of vorinostat to 200 mg thrice a day on the concurrent schedule resulted in increased toxicities with 2 of 2 patients developing DLTs. Within the sequential schedule, dose level -1b (decitabine 10 mg/m2/day on days 1-5 and vorinostat 200 mg twice a day on days 6-12) was more favorable in dose delivery without delays and therefore it represents the dose we recommend for further phase II evaluation. Dose level -1b on the sequential schedule also had the highest percentage of patients achieving stable disease for ≥ 4 cycles. Although this represents only a small number of patients, rendering it impossible to draw any definitive conclusion regarding superiority of any of the dose levels studied, we believe this dose level warrants further investigation in clinical trials.
Combination therapies employing DNMTi or HDACi with other agents are being pursued clinically. (8, 9) A small number of clinical trials have evaluated different combinations of epigenetic agents in patients with hematologic and, more recently, solid malignancies. (22, 24-27) There is optimism that combined epigenetic therapy can result in increased antitumor activity in comparison to the use of single-agent DNMTi or HDACi, but this needs validation in randomized studies. In our study we observed stable disease in previously progressing patients with different tumor types, but it is not possible to establish if this is due to the combination of the two agents and what the expected outcomes would be if each agent was used alone. Decitabine and vorinostat are active in hematologic malignancies and cutaneous T cell-lymphomas, respectively, but their role in the treatment of solid tumors remains undefined. Among the two agents, vorinostat has shown single-agent antitumor activity with reports of stable disease and a few cases of partial responses in patients with different types of solid tumors. (16, 28) This was a small phase I study and it is difficult to speculate based on its results in which tumor types this combination should be further explored. Recently reported studies of vorinostat in patients with solid tumors as single-agent or in combination with chemotherapy have shown preliminary evidence of activity in non-small cell lung, breast, colorectal, mesothelioma, thyroid and adenoid cystic carcinoma. (16, 28-30) It is therefore reasonable to consider further clinical investigation of this combination in the context of the abovementioned malignancies.
Hypermethylation of cytosines in CpG dinucleotides in the promoter regions of tumor-suppression genes and deacetylation of amino acid residues on the histone tails of nucleosomes, represent two epigenetic mechanisms of gene silencing that can contribute to tumor formation and progression. This phase I targeted combination trial evaluates the safety, tolerability, pharmacokinetics and preliminary antitumor activity of the hypomethylating agent decitabine, plus the histone deacetylase inhibitor vorinostat, in patients with advanced solid tumors. Sequential and concurrent administration schedules of these two agents were studied. Dose-limiting toxicities consisted mainly of myelosuppression, constitutional and gastrointestinal symptoms. Disease stabilization for four or more cycles was observed in about 30% of patients. While the combination of these two types of epigenetics-modulating agents has been examined in hematological malignancies, this study represents one of the first attempts of this strategy in advanced solid tumors.
Supplementary Figure A1: Vorinostat AUCt for the two different schedules at the dose of 200 mg twice daily.
Supported by NCI Grants. U01CA132123, U01CA099168, and P30-CA47904