Addition Of Gefitinib Research Articles

Analyses of putative anti-cancer potential of three STAT3 signaling inhibitory compounds derived from Salvia officinalis

The extract of Salvia officinalis (Common Sage) exhibited inhibitory activity of STAT3 signal after screening of several plants extracts using the STAT3-responsive reporter system. Cirsiliol, luteolin, and carnosol were identified from the methanol extract of Silvia officinalis as inhibitors of STAT3 signaling and the effects of these three compounds on STAT3 protein or growth inhibition on cancer cells was compared. Luteolin at the dose of 90 μM clearly suppressed the phosphorylation of STAT3 induced by IL-6, while carnosol was prone to decrease total STAT3 proteins at high doses (>90 μM). Cirsiliol had almost no effect. Since the three compounds exhibited similar concentration-dependent suppression patterns in the reporter assay except for cirsiliol became plateau beyond 30 μM, these compounds appeared to function as STAT3 inhibitory factors in different ways. The direct anti-proliferative activity of three compounds was examined with or without the anti-cancer drug gefitinib using HepG2 and A549 cells. The anti-proliferative effect of the three compounds was additively enhanced by gefitinib. At the doses of 3.6 μM, statistically significant suppression of proliferation was observed in HepG2 cells only by cirsiliol among the three compounds in the absence of gefitinib but all three compounds were prone to suppress the proliferation of HepG2 cells and A549 cells dose-dependently although cirsiliol showed a modest dose-dependency and this suppression of proliferation was enhanced by the addition of gefitinib. Cirsiliol, a dimethyoxylated flavone, activated the natural killer activity of KHYG-1 cells against erythroleukemia K562 cells like a hexamethoxylated flavone, nobiletin, suggesting that it may also have an indirect anti-cancer potential through activation of NK cells. These results shed light on the putative anti-cancer potential of Salvia officinalis.

Binding site identification of anticancer drug gefitinib to HSA and DNA in the presence of five different probes

This study was carried out to evaluate the binding interaction of gefitinib (GEF) with human serum albumin (HSA) and calf thymus DNA (ct-DNA) using fluorescence, UV–Visible, zeta potential measurements and molecular docking methods in order to understand its pharmacokinetic mechanism. By increasing the temperature, a steady decrease in Stern–Volmer quenching constants was observed for HSA binding properties; this indicates a static type of fluorescence quenching. Negative values were calculated for Gibbs free energy (ΔG), enthalpy (ΔH), and entropy (ΔS) changes, indicating that the reaction is spontaneous and enthalpy-driven. Probe competitive experimental results showed that GEF contains the same binding site as warfarin and are consistent with modeling results. The zeta potential of the HSA increased with increasing GEF, which represents the presence of electrostatic interactions in the system. DNA binding properties were investigated in the presence of three probes. The experimental results showed that by increasing GEF to DNA-AO (acridine-orange) and DNA-MB (methylene-blue) system, the fluorescence intensity and absorbance spectra had no considerable change. Furthermore, with the addition of GEF to DNA, the zeta potential decreased gradually, indicating that the hydrophobic interaction between the GEF and the bases of DNA is the major factor. Thus, GEF can bind to DNA via a groove binding mode. It was also found that GEF entered into the minor groove in the A–T rich region of DNA fragment and bind via van der-Waals forces and three H-bond with double strands of DNA. This is in good agreement with experimental results.

AT-43 * MULTI-CENTRE, RANDOMIZED, DOUBLE-BLIND PHASE II STUDY COMPARING CEDIRANIB (AZD2171) PLUS GEFITINIB (IRESSA, ZD1839) WITH CEDIRANIB PLUS PLACEBO IN SUBJECTS WITH RECURRENT/PROGRESSIVE GLIOBLASTOMA

BACKGROUND: The vascular endothelial growth factor receptor (VEGFR) 2 tyrosine kinase inhibitor cediranib failed to improve outcome in recurrent glioblastoma in a randomized phase III trial (Batchelor et al.). One resistance mechanism for cediranib is through up-regulation of epidermal growth factor receptor (EGFR). This study was designed to test if the efficacy of cediranib is improved with the addition of gefitinib (an EGFR inhibitor). METHODS: We planned to 1:1 randomize 112 subjects with recurrent/progressive glioblastoma to cediranib + gefitinib (C + G) or cediranib + placebo (C + P) (NCT01310855), with PFS as the primary endpoint. Secondary end-points: OS, radiographic response rate, PFS rate at 6 months, 12 months survival rate, steroid use, time to deterioration of neurological status, safety and tolerability. Recruitment was discontinued early following AstraZeneca's suspension of the cediranib programme. RESULTS: 38 subjects were randomized, the interim results on 34 subjects (17 in each arm) are currently available. 24 male and 10 female. Mean age 54 (range 30-71). KPS ≤80 (35%), >80 (65%). The base-line characteristics for subjects in the 2 arms of the study were well balanced. Median PFS (95% CI) C + G 4.0 mo (2.7, *n/c), C + P 4.1 mo (2.0, 7.3); 6 month PFS C + G 40%, C + P 26%; 12 month PFS n/c; C + G vs C + P HR = 0.49, 95% CI (0.22, 1.11, p = 0.15). OS (mo): Median C + G 7.7 (95% CI 3.8, n/c), C + P 5.5 (95% CI 2.5, 7.3); 12 month n/c; C + G vs C + P HR = 0.359, 95% CI (0.12, 1.1; p = 0.076). No safety concerns. CONCLUSIONS: These interim results demonstrate no difference in PFS, however there was a trend (p = 0.08) for improved OS with the combination. The final results of the study for all 38 subjects will be available. *n/c not calculable due to limited data at time of analysis

A retrospective analysis of the role of gefitinib in the definitive management of esophageal/gastroesophageal junction (E/GEJ) cancer.

e15000 Background: The role of epidermal growth factor receptor (EGFR) inhibition in resectable E/GEJ cancer is uncertain. We update and retrospectively compare results from two Cleveland Clinic trials of concurrent chemoradiotherapy (CCRT) and surgery; the second study differing only by the addition of gefitinib (G) to the treatment regimen. Methods: Eligibility required a diagnosis of E/GEJ squamous cell or adenocarcinoma (ACA), with an endoscopic ultrasound stage of at least T3, N1, or M1a (AJCC 6th). Patients (pts) in both trials received 5-FU (1000mg/m2/d) and cisplatin (20mg/m2/d) as continuous infusions over days 1-4 along with 30 Gy radiation at 1.5 Gy bid. Surgery followed in 4-6 weeks; identical CCRT was given 6-10 weeks later. The second trial added G, 250mg/d, on day 1 for 4 weeks, and again with postoperative CCRT for 2 years. Preliminary results and comparisons have been previously published. Results: Clinical characteristics were similar between the 80 pts on the G trial (2003-2006) and the 93 pts on the no-G trial (1999-2003): median age (58 vs. 59 years), male gender (91% vs. 86%), ACA (94% vs. 83%), and HER2 positivity (28% vs. 18%). Minimum follow-up for all pts was 5 years. Multivariable Cox analyses comparing the G vs. no-G pts and adjusting for statistically significant covariates demonstrated improved overall survival (HR 0.62, 95% CI 0.44-0.88, p=0.008), relapse-free survival (RFS) (HR 0.59, 95% CI 0.41-0.84, p=0.003), and distant metastatic recurrence (HR 0.64, 95% CI 0.43-0.96, p=0.03), but not locoregional recurrence. Further subgroup analyses demonstrated improved RFS with G in pts not experiencing a pathologic response (HR=0.59, 95% CI 0.38-0.92, p=0.021), with T4 or M1a disease at surgery (HR=0.33, 95% CI 0.13-0.87, p=0.024), or with HER2-negative tumors (HR=0.65, 95% CI 0.42-0.99, p=0.048). Conclusions: Although this retrospective comparison can only be considered exploratory, it suggests that gefitinib may improve clinical outcomes when combined with CCRT and surgery in the definitive treatment of E/GEJ cancer. Clinical benefit may be greatest in pts with a poor response to preoperative chemoradiation, and in those with HER2-negative tumors. Clinical trial information: NCT00258323.

Pemetrexed-carboplatin adjuvant chemotherapy with or without gefitinib in resected stage IIIA-N2 non-small cell lung cancer harbouring EGFR mutations: A randomized phase II study.

7519 Background: Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) show great efficacy in patients with advanced non-small cell lung cancer (NSCLC) with EGFR mutations. The BR.19 trial exploring the role of adjuvant gefitinib in resected early stage NSCLC (stage IB 49%, II 38%, III 13%) did not show significant progression-free survival (PFS) or overall survival (OS) improvement in all patients. The efficacy of gefitinib following adjuvant chemotherapy in patients with EGFR mutation is unknown. Methods: In this open-label, phase II study, patients with resected stage IIIA-N2 NSCLC harbouring EGFR mutations (either the exon 19 deletion or L858R point mutation) were randomly assigned to receive pemetrexed (500mg/m2) and carboplatin (AUC=5), administered every 21 days for 4 cycles, followed with (n=30) or without (n=30) gefitinib (250mg per day) for 6 months. The primary end point was PFS. The second end point was OS. Results: From August 2008 toSeptember 2011, 60 patients (35 males and 25 females) were included in our center. Of the 60 patients (56 adenocarcinomas, 2 squamous cell carcinomas, 2 adenosquamous carcinomas), 20 patients (33.3%) had exon 19 deletion mutation, 40 (66.7%) patients had exon 21 L858R point mutation. The most common adverse event was rash (43.3%, 13 of 30) in the pemetrexed and carboplatin (PC)-gefitinib group and the addition of gefitinib to chemotherapy was well tolerated. The PFS was significantly longer among those who received PC-gefitinib than among those who received PC alone (median,39.8 months vs 27.0 months; hazard ratio [HR],0.369; 95% confidence interval [CI], 0.161-0.847; P=0.014). There was no significant difference in OS between the two group(median,41.6 months vs 32.6 months,P=0.066). The rates of 2-year PFS and OS were 78.9% and 92.4% in PC-gefitinib group, and 54.2% and 77.4% in PC alone group, respectively. Conclusions: The addition of gefitinib to pemetrexed and carboplatin adjuvant therapy showed significant improvement in PFS for patients with resected stage IIIA-N2 NSCLC harbouring EGFR mutations.

Epidermal Growth Factor Receptor Tyrosine Kinase Defines Critical Prognostic Genes of Stage I Lung Adenocarcinoma

PurposeTo identify stage I lung adenocarcinoma patients with a poor prognosis who will benefit from adjuvant therapy.Patients and MethodsWhole gene expression profiles were obtained at 19 time points over a 48-hour time course from human primary lung epithelial cells that were stimulated with epidermal growth factor (EGF) in the presence or absence of a clinically used EGF receptor tyrosine kinase (RTK)-specific inhibitor, gefitinib. The data were subjected to a mathematical simulation using the State Space Model (SSM). “Gefitinib-sensitive” genes, the expressional dynamics of which were altered by addition of gefitinib, were identified. A risk scoring model was constructed to classify high- or low-risk patients based on expression signatures of 139 gefitinib-sensitive genes in lung cancer using a training data set of 253 lung adenocarcinomas of North American cohort. The predictive ability of the risk scoring model was examined in independent cohorts of surgical specimens of lung cancer.ResultsThe risk scoring model enabled the identification of high-risk stage IA and IB cases in another North American cohort for overall survival (OS) with a hazard ratio (HR) of 7.16 (P = 0.029) and 3.26 (P = 0.0072), respectively. It also enabled the identification of high-risk stage I cases without bronchioalveolar carcinoma (BAC) histology in a Japanese cohort for OS and recurrence-free survival (RFS) with HRs of 8.79 (P = 0.001) and 3.72 (P = 0.0049), respectively.ConclusionThe set of 139 gefitinib-sensitive genes includes many genes known to be involved in biological aspects of cancer phenotypes, but not known to be involved in EGF signaling. The present result strongly re-emphasizes that EGF signaling status in cancer cells underlies an aggressive phenotype of cancer cells, which is useful for the selection of early-stage lung adenocarcinoma patients with a poor prognosis.Trial RegistrationThe Gene Expression Omnibus (GEO) GSE31210

β1‐adrenergic receptor‐mediated transactivation of epidermal growth factor receptor acutely regulates cardiac gene expression

β1‐adrenergic receptor (β1AR)‐mediated transactivation of epidermal growth factor receptor (EGFR) has been shown provide cardioprotection. While the mechanisms responsible for this effect are unknown, we hypothesized that β1AR‐mediated EGFR transactivation could modulate cardiac gene expression. To test this hypothesis, C57BL/6 mice were treated with isoproterenol (ISO) in the presence or absence of an EGFR antagonist (Gefitinib or AG1478). Following 10 minutes of stimulation, phosphorylation of ERK1/2 and Akt were each shown to be increased in response to ISO, and significantly ablated in the presence of AG 1478. Assessment of the subcellular localization of phosphorylated ERK1/2 and Akt in rat neonatal cardiomyocytes in response to β1AR‐mediated EFGR transactivation revealed significant increases in the nucleus, which were ablated by EGFR inhibition. To determine the impact of β1AR‐mediated EGFR transactivation on acute gene expression responses in the heart, mice were treated for 1 hour as described above and real‐time PCR was performed on a panel of EGFR‐regulated pro‐ or anti‐apoptotic genes. Of these, Bcl2l11 expression increased significantly in response to ISO and was attenuated with the addition of gefitinib. Altogether, these results reveal that β1AR‐mediated EGFR transactivation induces differential ERK1/2 and Akt targeting and selective regulation of cardiac gene expression. Funding was provided by the National Institutes of Health (HL‐105414 to DGT).

Abstract A154: Preclinical investigation of gefitinib combined with radiation in EGFR-mutation positive non-small cell lung cancer.

Abstract A subset of non-small cell lung cancer (NSCLC) patients with EGFR mutation positive tumors gain marked clinical benefit from treatment with EGFR tyrosine kinase inhibitors (TKIs), although the benefits can be short-lived as drug resistance emerges. This preclinical study investigated the potential of EGFR TKI treatment to augment the activity of radiotherapy in EGFR mutation positive human NSCLC cell lines. Sensitivity to the EGFR TKI gefitinib (0−3.0 μM) or radiotherapy (0–6 Gy) was assessed using clonogenic survival assays. For combination studies, clonogenic assays were performed on NSCLC cells exposed to a single dose of radiation (3 Gy) and 24 h exposure to gefitinib (0.1 μM). Effects on receptor signal transduction pathways (pEGFR, pAKT, pMAPK) and apoptosis (percentage cleaved/total PARP) were assessed by western blotting. DNA double strand break repair was assessed by counting residual H2AX foci by immunofluorescence 24 h after irradiation (3 Gy). NSCLC cell lines with activating EGFR mutations (PC-9 and HCC-827) were sensitive to both gefitinib (IC50 ± SEM 0.052 ± 0.007 M and 0.014 ± 0.004μM, respectively, n=6) and radiation (surviving fraction at 3 Gy ± SEM, SF3 = 0.76 ± 0.07 and 0.61 ± 0.03, respectively, n=6). Gefitinib treatment markedly reduced pEGFR (–72.1%), pAKT (−60.1%) and pMAPK (−92.5%) levels 4 h after treatment, and was associated with an increase in cleaved PARP (15.7%) but not in H2AX foci. Radiation treatment increased mean H2AX foci per cell (± SEM) from 9.3 ± 0.09 to 13.7 ± 0.31, (n=3, p=<0.01) and cleaved PARP (20%) but did not significantly affect pEGFR signaling. In contrast, NSCLC cell lines with an EGFR T790M mutation (H1975), or null for EGFR expression (H520), were insensitive to gefitinib (IC50 >3 μM) but were sensitive to radiation (SF3 = 0.43 ± 0.05 and 0.34 ± 0.05, respectively, n=6). Gefitinib treatment had no significant effect on EGFR signaling, cleaved PARP, or H2AX foci in H1975 or H520 cells, whereas radiation treatment increased levels of cleaved PARP (30.7%), compared with non-irradiated controls. In PC-9 and HCC-827 cells, the addition of gefitinib (0.1 μM, 24 h) to radiation reduced clonogenic survival (± SEM) by −30.8 ± 2.9% (P=0.03) and −46.2 ± 6% (P <0.01), respectively, compared with radiation alone, but had no significant effect on the radiation sensitivity of H1975 or H520. Following combination treatment in PC-9, there was a small increase (5.4%) in the levels of cleaved PARP compared with irradiation alone. However, there was no evidence of increased effects on EGFR signaling (pEGFR, pAKT, pMAPK) or DNA repair (H2AX foci) in the combination treatment in any of the cell lines tested. In conclusion, our data demonstrate that gefitinib treatment increases clonogenic cell killing by radiation, but only in cell lines sensitive to gefitinib alone. Our data provide no evidence for synergistic or mechanistic interactions between gefitinib and radiation and suggest that the combination of gefitinib and radiation may have the greatest potential against the subsets of lung cancers that are most sensitive to EGFR-TKIs, such as those harboring activating mutations in the EGFR gene. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr A154.

A phase II trial of cisplatin (C), gemcitabine (G) and gefitinib for advanced urothelial tract carcinoma: results of Cancer and Leukemia Group B (CALGB) 90102

Background: This phase II trial (Cancer and Leukemia Group B 90102) sought to determine the efficacy of cisplatin, standard infusion of gemcitabine and gefitinib in patients with advanced urothelial carcinoma.Patients and methods: Eligible patients had previously untreated measurable disease, Eastern Cooperative Oncology Group (ECOG) performance status of zero to two and creatinine clearance >50ml/min. Treatment consisted of cisplatin 70mg/m2 day 1 and gemcitabine 1000mg/m2 on days 1 and 8 given every 3 weeks concurrent with gefitinib 500mg/day orally for six cycles. Maintenance gefitinib 500mg/day was continued for responding or stable disease.Results: Fifty-four of 58 patients were assessable. Twelve patients (22%) had node-only disease, and 25 (46%) had an ECOG performance status of zero. There were 23 objective responses for an overall response rate of 42.6% [95% confidence interval (CI) 29.2% to 56.8%]. The median survival time was 15.1 months (95% CI11.1–21.7 months) and the median time to progression was 7.4 months (95% CI 5.6–9.2 months).Conclusions: The combination of cisplatin, gemcitabine and gefitinib is well tolerated and active in advanced transitional cell carcinoma. The addition of gefitinib does not appear to improve response rate or survival in comparison to historical controls of cisplatin and gemcitabine alone.

TIMP-1 and responsiveness of estrogen receptor negative breast cancer to preoperative epirubicin and cyclophosphamide with or without gefitinib.

Abstract Abstract #6072 Background: Tissue Inhibitor of Metalloproteinases-1 (TIMP-1) is a naturally occuring proteinase inhibitor, which inhibits most matrix metalloproteinases. It has previously been reported that high levels of tumor TIMP-1 is associated with lack of clinical benefit from anthracycline based chemotherapy in metastatic breast cancer and preliminary data suggest that this is also true for adjuvant treatment. Plasma TIMP-1 has also been shown to predict response to endocrine therapy in patients with metastatic breast cancer. No data regarding TIMP-1 response to neo-adjuvant treatment exists.
 Material and Methods: NICE (1839IL/0712) is a randomized phase II trial, assigning 144 patients per protocol with primary operable estrogen receptor negative breast cancer and tumor ≥ 2 cm to either four cycles of EC (epirubicin 90 mg/m2 and cyclophosphamide 600 mg/m2) plus placebo or EC plus gefitinib 250 mg daily. The primary endpoint was pCR (no invasive residual) at surgery and secondary endpoints were complete (CR) and overall objective (OR) tumor response rates (CR+PR) assessed by palpation, mammography and ultrasonography (the last prevailed in case of disagreements). Plasma TIMP-1 levels were measured (blinded and in duplicates) before and after preoperative EC using a validated enzyme-linked immunosorbent assay.
 Results: 'pCR was attained by 8/71 patients in the EC + gefitinib group and 8/73 patients in the EC + placebo group, and OR by 50 patients in each treatment group. The addition of gefitinib to pre-operative EC was not associated with any significant benefit, thereby justifying pooling of the 2 groups of patients. TIMP-1 ranged from 55.1 to 519 ng/ml, median 126.8 ng/ml at baseline. Patients who obtained pCR had numeric higher plasma TIMP-1 values than non-responders (155.2ng/ml against 139.9 ng/ml, p=0.35). Dichotomizing patients by the plasma TIMP-1 median showed, that patients with elevated TIMP-1 had a numeric increased likelihood of obtaining pCR and OR: Patients with plasma TIMP-1 above the median had a numeric higher pCR rate (6.6% against 4.4%; odds ratio 1.60, p=0.39), and OR (51.0% against 49.0%; odds ratio 1.20, p=0.61). A small decline in TIMP-1 was observed after four cycles of EC (median difference 4.5, 25% and 75% quartile of -28.6 and 27.9, p=0.85) and the change was nearly the same in responders as in non-responders.
 Conclusion: This study could not demonstrate a predictive role of pre-treatment plasma TIMP-1 in neo-adjuvant chemotherapy for primary breast cancer. A change in plasma levels of TIMP-1 during 4 cycles of EC was not associated with response to the treatment. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6072.

Gefitinib (Iressa) Potentiates the Effect of Ionizing Radiation in Thyroid Cancer Cell Lines

To determine whether inactivation of epidermal growth factor receptor (EGFR) kinase activity will sensitize thyroid cancer cell lines to ionizing radiation-induced death. Established human thyroid cancer cells lines were studied. Colony formation assay was used to determine the effect of Gefitinib, a small molecule inhibitor of EGFR, on anaplastic (ARO) and follicular (WRO) thyroid cancer cell lines. In addition, colony formation assay was used to determine the effect of ionizing radiation in the presence or absence of Gefitinib. EGFR protein expression on the cell lines and inactivation of EGFR kinase by Gefitinib was analyzed by Western blot. Immunohistochemistry was performed on archived thyroid cancer tissue to demonstrate expression of EGFR. Incubation with Gefitinib caused decreased phosphorylation of EGFR protein in established thyroid cancer cell lines as measured by Western blot. Inhibition of EGFR kinase activity by Gefitinib resulted in a dose-dependent decrease in colony formation in both ARO and WRO thyroid cancer cell lines. Addition of Gefitinib in combination with ionizing radiation reduced cell proliferation in ARO (P = .0084) and WRO (P = .0252) as measured by colony formation assay. Inactivation of the EGFR kinase by Gefitinib potentiates the ionizing radiation-induced inhibition of cell proliferation in thyroid cancer cell lines. Use of this combination treatment of Gefitinib and ionizing radiation may be a promising therapy for anaplastic thyroid and metastatic follicular thyroid cancer and should be extended into animal models.

Gefitinib plus concomitant boost accelerated radiation (AFX-CB) and concurrent weekly cisplatin for locally advanced unresectable squamous cell head and neck carcinomas (SCCHN): A phase II study

6031 Background: Molecular inhibition of EGFR signaling represents one of the most promising current advances for the treatment of SCCHN. This study assesses the feasibility, toxicity and efficacy of gefitinib along with AFX-CB regimen and weekly cisplatin in treatment- naïve patients (pts) with locally advanced unresectable SCCHN. Methods: Eligible pts had stage III-IV SCCHN, exclusive of nasopharyngeal cancer. Tumors had to be considered unresectable by a multidisciplinary head/neck tumor board. AFX-CB dose was 72 Gy in 42 fractions over 6 weeks, delivered in 1 daily fraction of 1.8 Gy during the first 3.5 weeks and 2 fractions per day, 1.8 Gy and 1.5 Gy separated by a 6-hour interval, during the last 2.5 weeks. Cisplatin (40 mg/m2) was given weekly for the first 4 weeks. Gefitinib (250 mg PO OD) was started 1 day before radiochemotherapy (RCT) and continued 3 months after the end of AFX-CB. Response was evaluated 3 months after radiotherapy using RECIST criteria. Mucosal and skin toxicities were evaluated using the RTOG scale. Results: From Dec 2002 to Dec 2004, 46 pts with SCCHN, ECOG PS 0–1 and adequate hematologic and renal functions were included. Median age was 55 years (range, 39 to 75); T4, 73%; N2/3, 61%; stage IV disease, 93%. Four pts did not complete the concomitant treatment (1 PD/3 toxicity) and 8 pts did not complete the gefitinib monotherapy phase due to PD. Grade 3 and 4 toxicity was consistent with previous RCT or single agent gefitinib trials, and included mucositis (40% and 7%, respectively), radiation dermatitis (14% and 0%), skin rash (5% and 0%), and diarrhea (2% and 0%). Chemotherapy-associated toxicity was mild with only 2 cases of grade 3 neutropenia and 3 cases of grade 3 anaemia. Three months after AFX- CB, 24 pts (52%) achieved a complete remission, 5 pts (11%) a partial remission, and 17 pts (37%) were non-responders (SD, PD, and not evaluable). With a median follow-up of 23 months (range 1–43) 2-year PFS and OS are 47% and 56% respectively. Conclusions: The addition of gefitinib to radiochemotherapy appears tolerable and feasible. Efficacy is encouraging for this poor prognosis population, and further development of this targeted combined-modality paradigm is warranted. No significant financial relationships to disclose.

Treatment of Human Epidermal Growth Factor Receptor 2-Overexpressing Breast Cancer Xenografts With Multiagent HER-Targeted Therapy

Human epidermal growth factor receptor 2 (HER2) is a member of the HER signaling pathway. HER inhibitors partially block HER signaling and tumor growth in preclinical breast cancer models. We investigated whether blockade of all HER homo- and heterodimer pairs by combined treatment with several inhibitors could more effectively inhibit tumor growth in such models. Mice carrying xenograft tumors of HER2-overexpressing MCF7/HER2-18 (HER2-transfected) or BT474 (HER2-amplified) cells were treated with estrogen supplementation or estrogen withdrawal, alone or combined with tamoxifen. One to three HER inhibitors (pertuzumab, trastuzumab, or gefitinib) could also be added (n > or = 8 mice per group). Tumor volumes, HER signaling, and tumor cell proliferation and apoptosis were assessed. Results were analyzed with the t test or Wilcoxon rank sum test and survival analysis methods. All statistical tests were two-sided. Median time to tumor progression was 21 days for mice receiving estrogen and 28 days for mice receiving estrogen and pertuzumab (difference = 7 days; P = .001; hazard ratio [HR] of progression in mice receiving estrogen and pertuzumab versus mice receiving estrogen = 0.27, 95% confidence interval [CI] = 0.09 to 0.77). Addition of gefitinib and trastuzumab to estrogen and pertuzumab increased this time to 49 days (difference = 21 days; P = .004; HR of progression = 0.28, 95% CI = 0.10 to 0.76). MCF7/HER2-18 tumors disappeared completely and did not progress (for > or = 189 days) after combination treatment with pertuzumab, trastuzumab, and gefitinib plus tamoxifen (19 of 20 mice) or plus estrogen withdrawal (14 of 15 mice). Both combination treatments induced apoptosis and blocked HER signaling and proliferation in tumor cells better than any single agent or dual combination. All BT474 tumors treated with pertuzumab, trastuzumab, and gefitinib disappeared rapidly, regardless of endocrine therapy, and no tumor progression was observed for 232 days. Combined treatment with gefitinib, trastuzumab, and pertuzumab to block signals from all HER homo- and heterodimers inhibited growth of HER2-overexpressing xenografts statistically significantly better than single agents and dual combinations.

Phase II combination of gefitinib and docetaxel for advanced or metastatic non-small cell lung cancer: clinical results and biological monitoring

The epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor gefitinib and the cytotoxic agent docetaxel are both used for the second-line treatment of advanced non-small cell lung cancer (NSCLC). This study aimed to investigate the efficacy and safety of gefitinib in combination with docetaxel within this disease setting, and to evaluate the predictive value of assessing pre-treatment levels of soluble serum EGFR and HER2. In this open-label, non-comparative, multicenter, phase II trial, patients with non-resectable advanced or metastatic NSCLC were treated with oral gefitinib (250 mg/day) in combination with docetaxel (75 mg/m2 IV every 3 weeks). Forty-eight patients were enrolled: 30 had progressed during or after platinum-based chemotherapy (Group A) and 18 were unsuitable for platinum-based chemotherapy (Group B). Anti-tumor activity was seen with objective response rates of 23.3% (Group A) and 11.8% (Group B). The most frequent adverse events considered to be gefitinib-related were diarrhea (57.4%) and skin-related events (dry-skin: 31.9%; rash: 29.8%; pruritus: 12.8%), and those considered to be docetaxel-related were alopecia (21.3%), nausea (19.1%), and diarrhea (17.0%). The addition of gefitinib did not seem to affect the hematological toxicity seen with docetaxel. Serum biomarker investigations revealed that patients who responded had lower serum EGFR levels than non-responders, although this association was not significant (p=0.07). In conclusion, the combination of gefitinib with docetaxel was feasible, generally well tolerated, and has activity for the treatment of advanced NSCLC. Soluble serum EGFR (and HER2 levels) did not appear to be predictive for response. Although this study confirms that the combination of gefinitib and docetaxel appears promisingly effective and tolerable, it should not be recommended as a standard option for second-line therapy in non-small cell lung cancer until results from phase III trials showing a significant superiority over docetaxel alone are available.

Biological and clinical outcomes from a phase II placebo-controlled neoadjuvant study of anastrozole alone or with gefitinib in postmenopausal women with ER/PgR+ breast cancer (Study 223)

515 Background: Gefitinib, an EGFR-tyrosine kinase inhibitor, reduces breast cancer cell growth and potentiates endocrine therapy in model systems. This double-blind multicentre study compared anastrozole 1 mg/day alone with anastrozole + gefitinib 250 mg/day as neoadjuvant therapy for breast cancer in a novel design aiming to assess additional benefit from gefitinib in individual patients. Methods: Postmenopausal women with stage I-IIIB breast cancer and ER and/or PgR+ tumours received anastrozole for 16 wks and were randomised (2:5:5 ratio) to: combination with gefitinib for 16 wks (AG); placebo for 2 wks then gefitinib for 14 wks (A:AG, to test for additional Ki67 suppression); placebo for 16 wks (A alone). Biopsies were taken at baseline, 2 and 16 wks. Primary comparison was change in Ki67 by 16 wks. Secondary comparison was objective tumour response rate (ORR) using UICC/WHO criteria at 16 wks. Results: 206 patients (pts) were randomised: (31 AG, 90 A:AG, 85 A alone); demography was well balanced between the groups. 109 pts were evaluable for Ki67: 59 AG + A:AG; 50 A alone. Change in Ki67 levels at 16 wks was not significantly different in those pts who received gefitinib + anastrozole versus anastrozole alone (p=0.257). The addition of gefitinib after 2 weeks of anastrozole did not further suppress Ki67 levels (p=0.164). 188 pts were evaluable for ORR (109 AG + A:AG; 79 A alone). The ORR was 48% in pts who received gefitinib + anastrozole and 61% in pts treated with anastrozole alone (p=0.067). Conclusions: Neither the biological nor the clinical activity of anastrozole was enhanced by the addition of gefitinib; although non-significant, both endpoints unexpectedly suggested a trend against the combination in this patient population. Molecular investigations of signal transduction pathways are underway to understand the significance of these findings. [Table: see text] [Table: see text]

A randomised phase II trial assessing the impact of the addition of gefitinib to the combination of radiotherapy and short-term maximal androgen blockage in high-risk localised prostate cancer: Safety evaluation

14613 Background: Given the in-vitro evidence of potential increase in tumour radiosensitisation and hormonal deprivation-related tumour growth inhibiting effect by the addition of EGFR inhibitors, a randomised unblinded phase II trial was initiated to evaluate the impact of the addition of gefitinib to a combination of radiotherapy (RT) and maximal androgen blockage (MAB) in patients (pts) with high-risk localised prostate cancer. Methods: Eligible pts had biopsy proven localised prostate carcinoma Gleason score ≥7 and/or cT3 stage and/or initial PSA ≥ 20; without nodal and distant metastases. All pts were treated by 8 months MAB using LH-RH agonist (Zoladex 3.6 mg/month) and peripheral anti-androgen (Casodex 50 mg/day), and localised Conformal RT (Prostate + Seminal Vesicles, 75.6 Gy/42 daily fractions), initiated after 4 months of MAB. Pts were randomised to receive or not gefitinib 250 mg/day concomitantly for 8 months. The planned accrual was 98 pts. The end-points were ASTRO defined PSA-relapse-free survival at 18 months and toxicity. A safety evaluation was performed mid 2005. Results: 20 pts (10 per arm) were included from 10/2003 to 02/2005. No significant difference in RT or MAB-related toxicity was seen between the 2 arms. The addition of gefitinib significantly increased the frequency and intensity of reversible skin toxicity events (Rash-CTC grade 3–4: 4 pts Vs O pts, p = 0.04), with a trend for reversible transaminase enzymes elevation (TEE) (CTC grade 3–4: 2 pts Vs 0 pts). No treatment interruption was reported in the control arm. In the experimental arm, 3 pts completed treatment, 3 pts had a temporary (<10 days) gefitinib discontinuation (reversible asthenia and skin rash) and 4 pts had a permanent gefitinib discontinuation for reversible CTC grade 3 toxicity (skin rash: 2 pts, TEE: 2 pts). Conclusions: Gefitinib-related toxicity led to treatment discontinuation in 4 out of 10 patients. The trial is under review. This trial was supported by AstraZeneca. No significant financial relationships to disclose.

Induction chemotherapy + gefitinib followed by concurrent chemotherapy/radiation therapy/gefitinib for patients (pts) with locally advanced squamous carcinoma of the head and neck: A phase I/II trial of the Minnie Pearl Cancer Research Network

5543 Background: Concurrent chemotherapy/radiation therapy (RT) improves treatment outcome in pts with locally advanced unresectable squamous cancers of the head and neck. We previously reported a 51% 3-year disease-free survival with induction paclitaxel/carboplatin/5-FU followed by concurrent paclitaxel/carboplatin/RT. In this phase II trial, we added gefitinib, an EGFR inhibitor, to a similar chemoradiation regimen. Methods: All pts had squamous carcinoma of the head and neck, with at least one of the following: N1-N3 disease, T3 or T4 primary lesion, nasopharynx primary (except T1N0M0). Additional eligibility: no previous therapy, ECOG PS 0 or 1, adequate bone marrow, kidney, liver function; informed consent. All pts received initial docetaxel 60mg/m2 D1, 22; carboplatin AUC 5.0 D1, 22; 5-FU 200mg/m2, 24-hour CI, D1–43; gefitinib 250mg PO qd, D1–43. Beginning week 8, pts received RT, 1.8Gy single daily dose to total 68.4 Gy, and concurrent docetaxel 20mg/m2 weekly × 6 doses + gefitinib 250mg PO daily. At completion of therapy, pts were reevaluated with CT scans and endoscopy. Results: 45 pts entered this trial between 8/04 and 8/05. Pertinent clinical characteristics: clinical T3/T4, 17; N2/N3, 23. 42 pts (93%) completed induction chemotherapy. 34 pts (76%) have completed combined modality therapy and have been restaged. Response to treatment: 11 CR (32%); 18 PR (53%); 5 stable/progression (15%). After median follow-up 7 months, 9 patients (20%) have developed progressive cancer. Actuarial PFS and OS at 1 year are 68% and 86%, respectively. Grade 3/4 myelosuppression was common, and grade 3/4 mucositis occurred in all pts during combined modality therapy. One pt had a treatment-related death during combined modality therapy. The addition of gefitinib did not substantially increase toxicity. Conclusions: This combined modality regimen was feasible and produced high response rates in pts with locally advanced head and neck cancer. Toxicity was consistent with other effective combined modality regimens for these pts. Further follow-up is needed to better assess the benefit of this approach. [Table: see text]

Gefitinib Prevents Bleomycin-induced Lung Fibrosis in Mice

Transforming growth factor-alpha and epidermal growth factor (EGF), the ligands for EGF receptor (EGFR), stimulate fibroblast proliferation and play an important role in the pathogenesis of pulmonary fibrosis. Therefore, inhibition of the EGFR signal by an EGFR tyrosine kinase inhibitor (EGFR-TKI) may prevent pulmonary fibrosis. However, there is a possibility that blocking the EGFR signal may inhibit epithelial cell repair, thereby exaggerating lung fibrosis. To investigate the effect of EGFR-TK inhibition on lung fibrosis. We looked at the effects of the EGFR-TKIs gefitinib (20, 90, 200 mg/kg) and AG1478 (12 mg/kg) on a bleomycin-induced lung fibrosis model in mice. Gefitinib prevented lung fibrosis at all three doses. Furthermore, in those mice that did not receive bleomycin treatment, gefitinib at 200 mg/kg did not induce lung fibrosis. Immunohistochemistry revealed that phosphorylation of EGFR in lung mesenchymal cells induced by bleomycin was inhibited by gefitinib. AG1478 also attenuated the lung fibrosis. In vitro studies further demonstrated that the addition of gefitinib or AG1478 suppressed the EGFR ligand-induced proliferation of lung fibroblasts. These findings suggest that, in the preclinical setting, EGFR-TKIs may have a protective effect on lung fibrosis induced by bleomycin. Because these molecular targeted drugs may have differing effects depending on species and individuals, a cautious interpretation is warranted.

Use of the Epidermal Growth Factor Receptor Inhibitors Gefitinib and Erlotinib in the Treatment of Non-small Cell Lung Cancer: A Systematic Review

Inhibition of the epidermal growth factor receptor is a promising therapy in the treatment of non-small cell lung cancer (NSCLC). In this systematic review, we evaluated the role of the epidermal growth factor receptor inhibitors gefitinib and erlotinib in the treatment of patients with advanced NSCLC. Relevant randomized trials published as articles or abstracts were identified through a systematic search of the literature from 1975 to November 2005 by two independent reviewers. Twelve randomized trials met the predefined eligibility criteria for this systematic review. Four large placebo-controlled trials demonstrated that the addition of gefitinib or erlotinib to platinum-based first-line chemotherapy did not significantly improve overall survival or time-to-disease progression. A large placebo-controlled trial revealed a clinically and statistically significant survival benefit for erlotinib therapy as second- or third-line systemic therapy. The results of a single placebo-controlled trial and two phase II trials suggest that modest tumor response rates and symptom control can be achieved with gefitinib as second-line or subsequent therapy; however, a statistically significant survival benefit was not found for gefitinib compared with placebo. There is strong evidence to recommend against the use of gefitinib or erlotinib in combination with chemotherapy or as maintenance therapy after chemotherapy and radiation as a first-line treatment for advanced NSCLC. Erlotinib monotherapy is an effective treatment that can prolong survival for patients with advanced NSCLC whose disease has relapsed or recurred after prior chemotherapy. Although a significant survival benefit has not been demonstrated for gefitinib in a placebo-controlled study, the two randomized phase II trials suggest that gefitinib may provide clinically important symptomatic benefits.

Epidermal Growth Factor Receptor-Targeted Agents for Lung Cancer

Approximately 150,000 people were diagnosed with non-small cell lung cancer (NSCLC) in the United States in 2005. Most presented with inoperable advanced-stage disease. Although combination chemotherapy remains the standard treatment, median survival with these regimens is only 8 to 10 months. Recent advances in our understanding of lung cancer on a molecular level have led to the introduction of targeted therapies. We reviewed the mechanism of action of gefitinib and erlotinib as well as the results of phase I, II, and III trials with these drugs. No survival advantage was seen with the addition of gefitinib or erlotinib to combination chemotherapy in first-line treatment of advanced NSCLC. Erlotinib has shown a survival advantage over placebo in patients with NSCLC after first- or second-line chemotherapy. Recently, mutations in the epidermal growth factor receptor-tyrosine kinase domain have been identified. Patients who express these mutations have shown a higher probability of response to gefitinib. Combination chemotherapy remains the first-line treatment of advanced NSCLC. The benefit of alternating drug schedules and combinations has been small. Targeted therapies such as gefitinib and erlotinib, although to date have shown no survival advantage when combined with chemotherapy in the first-line setting, remain promising. Ongoing studies of patient characteristics of responding patients and molecular studies of tumors may help to identify patients most likely to respond to these therapies.