Phase I clinical trial of the Src inhibitor dasatinib with dacarbazine in metastatic melanoma

University of California, San Francisco, MTZ-A741, 1600 Divisadero Street, San Francisco, CA 94143, USA.
British Journal of Cancer (Impact Factor: 4.84). 11/2011; 106(1):85-91. DOI: 10.1038/bjc.2011.514
Source: PubMed
ABSTRACT
Src inhibitors sensitise melanoma cells to chemotherapy in preclinical models. The combination of dasatinib and dacarbazine was tested in a phase I trial in melanoma.
Patients had ECOG performance status 0-2 and normal organ function. Dacarbazine was administered on day 1 and dasatinib on day 2 through 19 of each 21-day cycle. Both were escalated from 50 mg b.i.d. of dasatinib and 800 mg m(-2) of dacarbazine. Available pre-treatment biopsies were sequenced for BRAF, NRAS, and C-Kit mutations.
Dose-limiting toxicity was reached at dasatinib 70 mg b.i.d./dacarbazine 1000 mg m(-2), and was predominantly haematological. In 29 patients receiving dasatinib 70 mg b.i.d., the objective response rate (ORR) was 13.8%, the clinical benefit rate (ORR+SD) was 72.4%, the 6-month progression-free survival (PFS) was 20.7%, and the 12-month overall survival (OS) was 34.5%. Two out of three patients who were wild type for BRAF, NRAS, and c-KIT mutations had confirmed partial responses, and one had a minor response.
The recommended phase II dose is dasatinib 70 mg b.i.d with dacarbazine 800 mg m(-2). PFS and OS data for dasatinib at 70 mg b.i.d. with dacarbazine compared favourably with historical controls. Preliminary data support evaluating tumour mutation status further as a biomarker of response.

Full-text

Available from: Adil Daud, Jul 22, 2014
Phase I clinical trial of the Src inhibitor dasatinib with dacarbazine
in metastatic melanoma
AP Algazi
1
, JS Weber
2
, SC Andrews
2
, P Urbas
2
, PN Munster
1
, RC DeConti
2
, J Hwang
1
, VK Sondak
2
, JL Messina
2
,
T McCalmont
1
and AI Daud
*
,1
1
University of California, San Francisco, MTZ-A741, 1600 Divisadero Street, San Francisco, CA 94143, USA;
2
H Lee Moffitt Cancer Center, Tampa,
FL, USA
BACKGROUND: Src inhibitors sensitise melanoma cells to chemotherapy in preclinical models. The combination of dasatinib and
dacarbazine was tested in a phase I trial in melanoma.
METHODS: Patients had ECOG performance status 02 and normal organ function. Dacarbazine was administered on day 1 and
dasatinib on day 2 through 19 of each 21-day cycle. Both were escalated from 50 mg b.i.d. of dasatinib and 800 mg m
2
of
dacarbazine. Available pre-treatment biopsies were sequenced for BRAF, NRAS, and C-Kit mutations.
RESULTS: Dose-limiting toxicity was reached at dasatinib 70 mg b.i.d./dacarbazine 1000 mg m
2
, and was predominantly
haematological. In 29 patients receiving dasatinib 70 mg b.i.d., the objective response rate (ORR) was 13.8%, the clinical benefit
rate (ORR þ SD) was 72.4%, the 6-month progression-free survival (PFS) was 20.7%, and the 12-month overall survival (OS) was
34.5%. Two out of three patients who were wild type for BRAF, NRAS, and c-KIT mutations had confirmed partial responses, and
one had a minor response.
CONCLUSION: The recommended phase II dose is dasatinib70 mg b.i.d with dacarbazine 800 mg m
2
. PFS and OS data for dasatinib at
70 mg b.i.d. with dacarbazine compared favourably with historical controls. Preliminary data support evaluating tumour mutation
status further as a biomarker of response.
British Journal of Cancer (2012) 106, 85 91. doi:10.1038/bjc.2011.514 www.bjcancer.com
Published online 29 November 2011
& 2012 Cancer Research UK
Keywords: melanoma; dasatinib; dacarbazine; Src; biomarkers
The incidence of melanoma is increasing rapidly worldwide. In the
United States, an estimated 8700 deaths (Jemal et al, 2010) result
annually from this disease. The development of metastatic disease
is associated with a dismal prognosis (Barth et al, 1995) and, until
recently, the FDA-approved therapeutic options were not asso-
ciated with a survival benefit (Atkins et al, 1999, 2000; Chapman
et al, 2011). Ipilimumab, an anti-CTLA-4 antibody, does confer a
modest survival benefit in this population, but survival is still
limited (median overall survival (OS) ¼ 10 11.2 months; Hodi
et al, 2010; Robert et al, 2011). Therapeutic strategies targeting
tumour-driving oncogenes now promise to revolutionise the
treatment of melanoma. In particular, the BRAF inhibitors
vemurafenib and GSK2118643 show evidence of clinical activity
in a large proportion of patients whose tumours harbour
BRAF
V600E/K
mutations (Flaherty et al, 2010; Kefford et al, 2010;
Chapman et al, 2011). However, about half of the cutaneous
melanoma tumours do not harbour BRAF mutations, and even in
patients with these mutations, responses to vemurafenib are
transient, lasting a median of 6.7 months (Chapman et al, 2011).
Therefore, the identification of additional therapeutic targets in
melanoma is urgently needed.
Given the role of invasion and metastasis in the clinical
progression of melanoma, strategies inhibiting these processes
could substantially impact the clinical course of the disease.
Src and the related Src family kinases signal through multiple
downstream intermediaries including STAT3 (Yu et al, 1995),
FAK, and b-catenin (Irby et al, 2005), and Src activation has been
implicated in decreased tumour cell adhesion, increased invasive-
ness, and increased motility (Buettner et al, 2008). Src activation
has been implicated in the pathogenesis of colon (Irby et al, 1999;
Kline et al, 2008), lung (Song et al, 2006), pancreas (Trevino et al,
2006), breast (Hiscox et al, 2006; Jallal et al, 2007; Morgan et al,
2009), and prostate cancer (Nam et al, 2005; Kotha et al, 2006). In
uveal melanoma, Src activation has been associated with the MAP
kinase pathway activation (Maat et al, 2009). Src is also frequently
activated in cutaneous melanoma (Niu et al, 2002; Homsi et al,
2009; Eustace et al, 2010), and Src overexpression increases
cutaneous melanoma cell proliferation and decreases adhesion
(Boukerche et al, 2010). Conversely, Src inhibition leads to
decreased proliferation and migration in melanoma cell lines
(Eustace et al, 2008, 2010).
Dasatinib is a multi-targeted small-molecule kinase inhibitor
that inhibits Src and c-Kit in low nanomolar range. C-Kit is
mutated in approximately 15 20% of acral and mucosal mela-
nomas (Beadling et al, 2008; Satzger et al, 2008; Torres-Cabala
Received 2 August 2011; revised 20 October 2011; accepted 25
October 2011; published online 29 November 2011
*Correspondence: Dr AI Daud; E-mail: adaud@medicine.ucsf.edu
Presented in part at the Annual Meeting of the American Society of
Clinical Oncology, Chicago, IL, 2010.
British Journal of Cancer (2012) 106, 85 91
&
2012 Cancer Research UK All rights reserved 0007 0920/12
www.bjcancer.com
Clinical Studies
Page 1
et al, 2009), and marked objective tumour responses have been
observed in patients with exon 11 and exon 13 c-Kit mutant
melanoma treated with dasatinib. In one case, this occurred even
after disease progression on imatinib (Woodman et al, 2009).
In melanoma cell lines that have not been selected for c-Kit
mutations, dasatinib decreases cellular proliferation (Eustace et al,
2010) and enhances apoptosis (Niu et al, 2002), and dasatinib
decreases cell migration even in cells in which it has no anti-
proliferative effect (Eustace et al, 2008, 2010). Dasatinib may also
inhibit the formation of new melanoma lung metastases in vivo
(Fraser et al, 2010). Dasatinib monotherapy is only modestly active
in melanoma patients unselected for c-Kit mutations. In a phase II
clinical trial, 36 metastatic melanoma patients were treated with
dasatinib dosed at 70 100 mg PO b.i.d. Two partial responses were
reported and the 6-month progression-free survival (PFS) rate was
13% (Kluger et al, 2011). One responding patient had a confirmed
c-Kit mutation in exon 13; the other was a c-KIT wild type. Four
c-KIT wild-type patients were described with prolonged stabilisa-
tion of disease lasting up to 136 weeks. Common dose-limiting
toxicities associated with dasatinib in this trial included pleural
effusions, dyspnoea, fatigue, and diarrhoea.
In addition to its single agent activity, cell-culture experiments
have demonstrated an antiproliferative synergy between dasatinib
and chemotherapeutic agents including cisplatin (Homsi et al,
2009) and temozolomide (Eustace et al, 2008) in c-Kit wild-type
melanoma. Dacarbazine is a commonly employed alkylating agent
with single-agent activity in advanced melanoma (Luikart et al,
1984; Chapman et al, 1999; Middleton et al , 2000; Schadendorf
et al, 2006). We conducted a phase I clinical trial of dasatinib in
combination with dacarbazine, to determine the safety and toler-
ability of this regimen in patients with advanced melanoma and
to identify a recommended phase II dose. Selective dose expan-
sion cohorts were evaluated for preliminary evidence of efficacy.
Tumours from a subset of patients were also evaluated for BRAF,
NRAS, and c-Kit mutations as a potential biomarker of response.
MATERIALS AND METHODS
Study design
This study was initially designed as a two-part study, with dose-
escalation and dose-expansion cohorts. The first three of these cohorts
included twice-daily dosing of dasatinib, and the remaining two cohorts
included once-daily dosing. The dose escalation for the twice-daily
dasatinib dosing schedule was based on a standard phase I dose escala-
tion (3 þ 3) scheme (Ratain et al, 1993). Dose expansion was eventually
carried out in multiple cohorts for evaluation of dose-limiting toxicity
(DLT) events and for better estimation of efficacy and toxicity. A total
of five cohorts were evaluated to identify the maximum tolerated dose
(MTD) of dacarbazine in combination with dasatinib (Bristol-Myers
Squibb, New York, NY, USA). Dosing was as follows: cohort 1,
dasatinib 50 mg PO b.i.d, dacarbazine 800 mg m
2
; cohort 2, dasatinib
70 mg PO b.i.d, dacarbazine 800 mg m
2
; cohort 3, dasatinib 70 mg PO
b.i.d, dacarbazine 1000 mg m
2
; cohort 4, dasatini b 140 mg PO daily,
dacarbazine 1000 mg m
2
; and cohort 5, dasatinib 100 mg PO daily,
dacarbazine 1000 mg m
2
. Written informed consent was obtained
from all patients before the initiation of pre-treatment screening
procedures. The Scientific Review Committees and the Institu-
tional Review Boards at the Moffitt Cancer Center in Tampa,
FL, USA, and at the University of California, San Francisco, CA,
USA, approved the trial. Accrual began in January 2008 and was
completed in August 2009.
Patients
Eligible patients had unresectable stage III or stage IV melanoma.
Patients were required to have measurable or evaluable disease,
and prior treatment with dacarbazine or temozolomide was not
allowed. All patients were required to have an ECOG performance
status of 0 2, adequate bone marrow function (absolute neutro-
phil count 41.5 10
9
l
1
, haemoglobin 49gdl
1
, platelets
4100 10
9
l
1
), renalfunction (creatinine o1.5 times the upper
limit of normal), and hepatic function (total bilirubin o1.5 times
the upper limit of normal, AST and ALT o2.5 times the upper
limit of normal). Patients with vascular events within 6 months
were excluded, as were patients with QTc prolongation (4470 ms)
and ongoing cardiac dysrhythmias. Patients with leptomeningeal
disease were excluded, but neurologically intact patients with
treated brain metastasis that had no evidence of recurrence for at
least 12 weeks were eligible.
Study treatment
All patients were treated with dacarbazine on day 1 of each 21-day
cycle, and dasatinib was taken orally on treatment days 2 through
19. Dasatinib was not given on treatment days 20, 21, and 1, due to
concern that it could decrease cellular proliferation and diminish
the efficacy of cytotoxic chemotherapy. Concurrent use of potent
CYP3A4 inhibitors or of medications known to prolong the QT
interval was prohibited. Before each dacarbazine infusion, patients
were pre-medicated with dexamethasone, ondansetron, and
lorazepam. Treatment was continued until disease progression,
withdrawal of consent, or the development of unacceptable
treatment-related toxicity.
Toxicity assessment
Pre-treatment assessments included a complete history and
physical examination, laboratories including a complete blood
count, a comprehensive metabolic panel, and a 12-lead electro-
cardiogram. Adverse events were graded using the Common
Terminology Criteria for Adverse Events version 3.0 at weekly
follow-up visits during the first 21-day treatment cycle, and every
three weeks thereafter. Dose-limiting toxicities were defined as any
grade 4 haematological toxicity (except asymptomatic grade 4
neutropenia lasting 7 days or less); prolonged grade 3 or 4
thrombocytopenia ( 47 days) or thrombocytopenia associated
with bleeding, requiring platelet transfusion; any grade 3 or 4 non-
haematological toxicity, despite optimal supportive care; and any
toxicity considered unacceptable by the study principal investi-
gator. The MTD was initially defined as the highest dose level at
which fewer than two out of six patients (o33%) experienced a
DLT in cycle 1, but post-DLT period events were ultimately taken
into consideration for defining the MTD. After the 21-day DLT
period, dose modifications were made for febrile neutropenia
(T438.51, ANC o1000 mm
3
); grade 3 or 4 thrombocytopenia,
persistent neutropenia (ANC o1000 mm
3
) or thrombocytopenia
(platelet count o100 000 ml
1
) on day 1 of any treatment cycle;
grade 2 or higher liver function abnormalities; diarrhoea; and any
other grade 3 or higher non-haematological toxicity other than
fever, chills, and flu-like symptoms.
Response assessment
Planned secondary endpoints included overall response rate
(ORR) by the Response Evaluation Criteria in Solid Tumours
(RECIST v1.0), OS and PFS. Patients receiving at least two cycles of
treatment and those taken off study, early for clinical disease
progression were considered evaluable for response. Tumour
assessments were made at baseline and at the end of every second
cycle (i.e. every 6 weeks). Partial and complete responses were
defined by the best treatment response achieved. Stable disease
was defined as maintenance of the sum of lesions diameters
between a 30% reduction and a 20% increase of overall tumour
size over 12 weeks or longer. Patients were assessed for adverse
Dacarbazine with dasatinib phase I trial in melanoma
AP Algazi et al
86
British Journal of Cancer (2012) 106(1), 85 91 & 2012 Cancer Research UK
Clinical Studies
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events on the basis of the clinical and laboratory data on treatment
days 1, 8, and 15 of the first 21-day cycle, then every 3 weeks on
day 1 of each subsequent cycle.
Statistics
Descriptive Kaplan Meier survival analysis was performed and
subgroup survival comparisons using log-rank were performed
using SPSS version 17 (Chicago, IL, USA).
Exploratory biomarker analysis
A post-hoc analysis of tumour mutation status as a predictor of
response was performed on the 12 of 46 evaluable patients who
had tissue available for analysis. Available pre-treatment, formalin-
fixed, paraffin-embedded specimens were used to prepare 5-mm
sections. Sections were microdissected to minimise stromal
contamination and were genotyped using the PCR for known
oncogenic mutations in BRAF exon 15, NRAS exons 1 and 2, c-Kit
exons 9, 11, 13, 17, and 18, GNAQ exon 5, and GNA11 exon 5. The
two patients with tumours positive for BRAF mutations were
identified through screening for a subsequent clinical trial of the
BRAF inhibitor PLX-4032 (NCT00949702).
RESULTS
Patients and treatment
A total of 51 patients were consented and screened for this study.
One patient was found to be ineligible. Another patient entered the
study with a diagnosis of melanoma of the soft parts, a disease that
is now considered a sarcoma subtype. The patient was included in
toxicity, but not response assessments. A total of 49 patients with
melanoma, who received any treatment on study, were also
considered evaluable for toxicity. Another 46 patients were
considered to be evaluable for response. Two inevaluable
melanoma patients did not complete two cycles of therapy due
to toxicity (N ¼ 2), and one withdrew consent (N ¼ 1) and did not
have restaging scans. Complete patient demographics are listed in
Table 1.
Toxicity and DLTs
The most common grade 3 and 4 adverse events were haemato-
logical (50% of patients overall), including neutropenia, anaemia,
and thrombocytopenia (Tables 2 and 3). No DLTs were observed
in cohorts 1 and 2. One of the first three patients in cohort 3
(dacarbazine 1000 mg m
2
, dasatinib 70 mg PO b.i.d) developed
dose-limiting thrombocytopenia, and the cohort was expanded to
6 and then to 14 patients to gain additional information regarding
treatment-associated toxicity. The sample sizes for cohort expan-
sions were based on the observation of latent (post-DLT period)
toxicities rather than pre-planned statistical considerations. Two
additional patients in the expansion of cohort 3 developed dose-
limiting febrile neutropenia. After the DLT period, one patient
developed refractory grade 3 diarrhoea, and another patient had a
myocardial infarction that was considered possibly related to
treatment. The latent toxicities observed in expansion cohort 3
precluded further clinical development at these dose levels, and
dacarbazine 800 mg m
2
with dasatinib 70 mg PO b.i.d was
designated as the MTD for twice-daily dosing of dasatinib. Cohort
2 was subsequently expanded to a total of 19 patients. This
regimen was generally well tolerated, with 9 of 19 patients (47%)
experiencing non-dose-limiting (generally transient) grade 3 and 4
haematological adverse events. Grade 3 and 4 non-hematologic
adverse events were limited to one patient with grade 3 dyspnoea,
two patients with grade 3 hyponatraemia, and one patient with
grade 3 hyperglycaemia.
Two regimens with once-daily dasatinib dosing were also
evaluated. One out of three patients in cohort 4 (dacarbazine
1000 mg m
2
with dasatinib 140 mg PO daily) developed dose-
limiting grade 3 thrombocytopenia and grade 3 dyspnoea during
the DLT period, and a second patient developed grade 3 dyspnoea
on cycle 2 day 15. On the basis of these events, dacarbazine
1000 mg m
2
with dasatinib 140 mg PO daily was thought to be too
toxic for further development. There were no DLTs in a total of
11 patients treated in cohort 5 (dacarbazine 1000 mg m
2
with
dasatinib 100 mg PO daily). Five patients in this cohort had non-
dose-limiting grade 3 and 4 haematological toxicities, one patient
developed grade 3 fatigue, and one patient had an episode of grade
3 gastrointestinal bleeding that was probably treatment related.
Further expansion of cohort 5 was not pursued due to the failure of
once-daily dasatinib dosing to induce objective tumour responses
in these 11 patients.
Response and survival
A total of 4 out of 29 evaluable patients (13.8%) receiving dasatinib
70 mg PO b.i.d. had partial responses by RECIST (Table 4), and 17
patients had stabilisation of disease for a clinical benefit rate
(ORR þ SD) of 72.4%. There were no objective responses in the
other three cohorts. Prolonged stabilisation of disease was
observed in all cohorts and in 26 out of 46 patients (56.5%)
overall. Clinical benefit (PR þ SD) was observed in 30 of 46
patients (65.2%). The median PFS in all patients was 13.4 weeks
and the median OS was 40.6 weeks. The median PFS in cohorts
Table 1 Patient demographics
Patient demographics (N ¼ 50)
Age (years) 62.3
±
12.1
Gender
Male (%) 31 (62)
Female (%) 19 (38)
Stage
M1a (%) 6 (12)
M1b (%) 13 (26)
M1c (%) 31 (62)
Prior treatment
Chemotherapy (%) 2 (4)
Vaccine (%) 1 (2)
None (%) 47 (94)
Baseline lactate dehydrogenase
Normal (%) 32 (64)
Elevated (%) 18 (36)
ECOG performance status
0 (%) 23 (46)
1 (%) 22 (46)
2 (%) 2 (4)
a
Primary site
Cutaneous
Torso (%) 13 (26)
Head and neck (%) 11 (22)
Extremity (%) 11 (22)
Multiple (%) 2 (4)
Unknown (%) 4 (8)
Ocular (%) 6 (12)
Mucosal (%) 2 (4)
Soft parts (%) 1
b
(2)
a
ECOG performance status was not documented for two patients.
b
Patient with
melanoma of the soft parts included in toxicity, but not response assessments.
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British Journal of Cancer (2012) 106(1), 85 91& 2012 Cancer Research UK
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15 was 5.1, 14.0, 13.4, 12.0, and 11.6 weeks, respectively. The
median OS in cohorts 1 5 was 63.9, 40.6, 40.9, 28.6, and 40.9
weeks, respectively. In all, 3 out of 12 patients genotyped were
wild type for BRAF, NRAS, c-KIT, GNAQ, and GNA11 mutations.
Two of these patients had objective tumour responses and one had
a minor response (Figure 1). In patients receiving dasatinib 70 mg
PO b.i.d., the 6-month PFS rate was 20.7% and the 12-month OS
rate was 34.5%.
Table 2 Toxicities possibly, probably, and definitely related to treatment
Dacarb/dasatinib Grade Heme GI Resp. Integ. Pain Constit. Lab Other
800/50 b.i.d. 1 and 2 Neutro (1)
Anaemia (2)
Platelets (1)
Nausea (2)
Diarrhoea (2)
Anorexia (2)
Dehydr (1)
Constip (1)
Alopecia (1) Headache (2) Fatigue (2) Low alb (2)
Low Na (1)
Low Ca (1)
Dizziness (1)
3 and 4
800/70 b.i.d. 1 and 2 Neutro (4)
Anaemia (14)
Platelets (11)
Anorexia (3)
Diarrhoea (8)
Nausea (13)
Constip (5)
Dysphagia (1)
Dysgeusia (1)
Anorexia (2)
Mucositis (1)
Effusion (1)
Dyspnea (2)
Oedema (1)
Rash (7)
Alopecia (2)
Flushing (3)
Headache (8)
Abdomen (1)
Myalgias (1)
Face (1)
Hand (1)
Fatigue (10)
Sweats (2)
Chills (3)
Insomnia (2)
Wt loss (1)
Fever (4)
High Mg (2)
Low Mg (2)
Low Ca (1)
High gluc (2)
Alk phos (5)
ALT (5)
AST (1)
Low alb (2)
Anxiety (1)
Oedema (5)
Numbness (2)
HSR (2)
Depress (1)
Polyuria (1)
Dizziness (1)
Neuropathy (1)
3 and 4 Neutro (6)
Anaemia (3)
Platelets (3)
Dyspnea (1) High gluc (1)
Low Na (1)
1000/70 b.i.d. 1 and 2 Neutro (2)
Anaemia (6)
Platelets (4)
Nausea (11)
Diarrhoea (7)
Er satiety (1)
Constip (1)
Anorexia (3)
Mucositis (1)
Tongue sw (1)
Effusions (3)
Atelect (1)
Cough (1)
Hiccups (1)
Dyspnea (1)
Rash (5)
Alopecia (3)
Pruritis (3)
Flushing (1)
Dry skin (1)
Foot (1)
Headache (4)
Myalgias (1)
Abdomen (2)
Fatigue (4)
Chills (2)
Fever (3)
Insomnia (1)
Low Ca (1)
Low K (1)
AST (1)
High gluc (1)
Long QT (5)
Tachycard (1)
Orthostasis (1)
Ging bleed (1)
Oedema (1)
3 and 4 Neutro (4)
Anaemia (4)
Platelets (7)
Diarrhoea (1) Oedema (1) Low Na (1) MI (1)
Neu fever (2)
1000/140 daily 1 and 2 Anaemia (3)
Platelets (2)
Dry mouth (1)
Nausea (2)
Constip (1)
Abd dist (1)
Anorexia (1)
Diarrhea (1)
Effusion (2) Rash (1) Headache (1)
Dysaesthesia (1)
Fatigue (3)
Chills (2)
Hot flash (1)
Wt loss (1)
Insomnia (1)
Sweats (1)
Alk phos (1)
Low Na (1)
Long QT (1)
Oedema (1)
Weakness (1)
3 and 4 Neutro (1)
Platelets (1)
Dyspnea (2)
1000/100 daily 1 and 2 Neutro (2)
Anaemia (3)
Platelets (3)
Nausea (6)
Anorexia (2)
Diarrhoea (2)
Dyspnea (1)
Cough (1)
Effusion (1)
Rash (4) Headache (2)
Abdomen (1)
Fatigue (6)
Fever (1)
Chills (1)
Alk phos (1)
ALT (2)
AST (1)
Epistaxis (1)
Oedema (2)
3 and 4 Neutro (5)
Platelets (1)
Fatigue (1) GI bleed (1)
Abbreviations: Abd dist ¼ abdominal distention; Alb ¼ albumin; Alk phos ¼ alkaline phosphatase; ALT ¼ alanine aminotransferase; AST ¼ aspartate aminotransferase;
Constip ¼ constipation; Constit. ¼ constitutional; Dehydr ¼ dehydration; GI ¼ gastrointestinal; gluc ¼ glucose; HSR ¼ hypersensitivity reaction; Integ. ¼ integument; MI ¼ myocardial
infarction; Neutro ¼ neutropenia; QT ¼ QT interval in the electrocardiogram; Resp. ¼ respiratory; Tongue sw ¼ tongue swelling; Wt ¼ weight. Only the highest-grade toxicity for
each patient is reported. Grade 3 and 4 toxicities are noted in shaded regions. The number of events is in parentheses.
Table 3 Individual patient DLTs (during DLT period, cycle 1, day 1 21) and proportion of patients with any grade 3 and 4 toxicity, possibly, probably, and
definitely related to treatment
Patients with grade 3 or 4 toxicity by category (%)
Cohort
(dacarbazine/dasatinib)
DLT
category (N) DLT (%) Heme Pulm Card Bleed Infect GI Cons
1. 800/50 b.i.d. 0
2. 800/70 b.i.d. 0 9/19 (47) 1/19 (5)
3. 1000/70 b.i.d. Heme (1)
NF (2)
a
21.4 10/14 (71) 1/14 (7) 1/14 (7)
b
2/14 (14)
c
1/14 (7)
d
4. 1000/140 q.d. Pulm (1)
Heme (1)
33 1/3 (33) 2/3 (67)
5. 1000/100 q.d. 0 5/11 (45) 1/11 (9)
e
1/11 (9)
f
Total 25/50 (50) 3/50 (6) 1/50 (2) 1/50 (2) 2/50 (4) 1/50 (2) 1/50 (2)
Abbreviations: Bleed ¼ bleeding; Card ¼ cardiac; Cons ¼ constitutional; DLT ¼ dose-limiting toxicity; GI ¼ gastrointestinal; Heme ¼ hematologic; Infect ¼ infection; NF ¼ neutropenic
fever; Pulm ¼ pulmonary.
a
Patients in expansion cohort.
b
Myocardial infarction, possibly related.
c
Febrile neutropenia.
d
Diarrhoea.
e
GI bleeding in the setting of
thrombocytopenia.
f
Fatigue.
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Additional subgroup analysis
There were no differences in PFS on the basis of gender, normal vs
elevated LDH, age, metastatic stage, or ocular vs non-ocular
primary. Median PFS by genotype was 5.7, 6, 17.3, and 34 weeks for
patients with BRAF (N ¼ 2), NRAS (N ¼ 4), GNAQ/GNA11 (N ¼ 3),
and wild-type (N ¼ 3) mutation status, respectively. Patients with
clinical benefit from dacarbazine and dasatinib had significantly
longer OS than those without (51.6 vs 22.3 weeks, Po0.01), and
there was a trend towards worse OS in patient with ocular vs non-
ocular primaries (22.9 vs 40.9 weeks, n.s.). There were no
differences in OS on the basis of gender, age, or metastatic stage,
and there were not enough events in the genotyped patients to
allow calculation of the median OS in all groups.
DISCUSSION
The Src family kinases has critical roles in the process of cancer
invasion (Kim et al, 2009), and preclinical data indicates that Src
inhibition may add to tumour control in advanced malignancies
including melanoma (Eustace et al, 2008; Homsi et al, 2009; Fraser
et al, 2010). In the current study, we show that dasatinib, a Src/abl
kinase inhibitor, can be safely combined with dacarbazine at an
adequate dose intensity. Dose expansion cohorts at three levels
were accrued to profile-delayed toxicities and to get a better
estimate of efficacy. Toxicities were primarily haematological,
and treatment discontinuations were required with post-cycle
1 therapy in patients receiving dasatinib 70 mg PO b.i.d with
dacarbazine 1000 mg m
2
IV every 3 weeks. At this dose level,
objective responses were noted in 2 out of 11 (18.2%) patients and
clinical benefit in 7 out of 11 (54.5%) patients. Treatment was
better tolerated in patients receiving 70 mg PO b.i.d with
dacarbazine 800 mg m
2
. Objective tumour responses were
observed in 2 patients (11%), and clinical benefit was observed
in 11 out of 18 patients (61.1%) in this cohort. On the basis of these
findings, the latter dose level would be appropriate for further
clinical trials. In contrast to a recent phase II study of dasatinib
monotherapy (Kluger et al, 2011), grade 3 and 4 pulmonary and
gastrointestinal toxicities were infrequent, occurring in only 2 of
33 patients (6.1%) receiving dasatinib 70 mg PO b.i.d. Grade 3
and 4 pleural effusions were not observed. The lower incidence of
these side effects in the present study may be due to the steroid
premedication used with dacarbazine, dacarbazine itself, or the
dasatinib dosing schedule that included a three-day pause in
dasatinib dosing on treatment days 20, 21, and 1. Of note, the first
17 patients treated in the prior study started with dasatinib dosed
at 100 mg PO b.i.d, and the majority of these patients required
early treatment interruptions due to treatment-associated toxicity.
The incidence of pulmonary and gastrointestinal toxicity was
markedly lower in patients enrolled subsequently at a dose of
70 mg PO b.i.d.
Dasatinib combined with dacarbazine appears to be more active
than either agent alone, with the caveat that cross-trial compar-
isons must be interpreted with extreme caution. In a phase II trial,
dasatinib monotherapy yielded a median PFS of 8 weeks and a 6
month PFS rate of 13% (Kluger et al, 2011). Similarly, patients
treated with dacarbazine alone typically demonstrate objective
disease progression on the first restaging scan (e.g. Chapman et al,
2011). In contrast, the median PFS for patients treated with
dacarbazine þ dasatinib was 13.4 weeks and the 6-month PFS rate
was 20.7%. Furthermore, both the 6-month PFS and 12-month OS
rates for dacarbazine and dasatinib compare favourably with
benchmarks established in the Korn et al (2008) meta-analysis
based on 42 trials, which completed accrual between 1975 and 2005
(6-month PFS ¼ 20.7% vs 14.5%, 95% CI 12.9 16.1%; 12-month
OS ¼ 34.5% vs 25.5%, 95% CI 23.6 27.4%). These findings suggest
that the addition of dasatinib to dacarbazine may decrease the
dissemination of advanced melanoma lesions, consistent with
reductions in tumour cell invasion and migration induced by
dasatinib in pre-clinical studies (Eustace et al, 2008, 2010).
The current study supports further exploration of BRAF/NRAS/
KIT wild-type status as one of several candidate biomarkers that
could help to identify patients who are most likely to benefit from
dacarbazine with dasatinib. The absence of BRAF and NRAS
mutations in melanoma cell lines is associated with a greater
sensitivity to dasatinib in vitro (Journe et al, 2010). Genotyping
data from the current study were limited by tissue availability and
subject to non-random selection. However, the finding that two of
four clinical responders to dasatinib with dacarbazine did not have
Table 4 Best tumour response by RECIST criteria as a function of
dacarbazine and dasatinib dose
Dacarbazine
(mg m
2
) Dasatinib
Not
evaluable PD (%) SD (%) PR (%) CR
800 50 mg b.i.d. 2/3 1/3
800 70 mg b.i.d. 1 5/18 (27.8) 11/18 (61.1) 2/18 (11.1)
1000 70 mg b.i.d. 3 3/11 (27.3) 6/11 (54.5) 2/11 (18.2)
1000 140 mg daily 1/3 2/3
1000 100 mg daily 5/11 (45.5) 6/11 (54.5)
Abbreviations: CR ¼ complete response; PD ¼ progressive disease; PR ¼ partial
response; RECIST ¼ Response Evaluation Criteria in Solid Tumours; SD ¼ stable
disease. Four patients were not evaluable for response due to adverse events before
the first restaging scans.
†This patient with an NRAS mutation had marked clinical progression at 3 weeks follow-up
*Pro
g
ression of non-tar
g
ets at first resta
g
in
g
–100
100
–50
0
(%)
50
A
B
70 b.i.d.
800
50 b.i.d.
b
800
c
70 b.i.d.
1000
140 q.d.
1000
100 q.d.
1000
*
*
*
*
*
a
100
NRAS
BRAF
GNAQ/G11
Wild type
80
*
60
40
20
0
–20
–40
–60
–80
–100
% Change in RECIST from baseline
Clinical progression
*Progression of non-targets.
a
Marked clinical progression at 3 weeks.
b
Dasatinib dose (mg) and frequency.
c
Dacarbazine dose (mg m
–2
)
Figure 1 (A) Best percent changes in overall RECIST score by treatment
group. *Progression of non-targets.
a
Marked clinical progression at 3 weeks.
b
Dasatinib dose (mg) and frequency.
c
Dacarbazine dose (mg m
2
).
(B) Exploratory analysis: best RECIST response by tumour mutation
status.
w
This patient with an NRAS mutation had marked clinical progres-
sion at 3 weeks follow-up. *Progression of non-targets at first restaging.
Dacarbazine with dasatinib phase I trial in melanoma
AP Algazi et al
89
British Journal of Cancer (2012) 106(1), 85 91& 2012 Cancer Research UK
Clinical Studies
Page 5
the BRAF/NRAS/c-Kit mutations is intriguing and bears further
evaluation in the context of a phase II clinical trial. Additional
candidate biomarkers could also be explored in such a trial
including caveolin-1, an Src substrate that influences c-Src kinase
activity. Caveolin-1 expression in melanoma is associated with
increased cellular proliferation (Felicetti et al, 2009; Trimmer et al,
2010), and in some studies, enhanced tumour cell invasion and
migration (Felicetti et al, 2009). Several studies have identified
elevated caveolin-1 expression as a biomarker of response to
dasatinib in breast, lung, and prostate cancer cells (Finn et al,
2007; Huang et al, 2007; Wang et al, 2007). Furthermore, in a
phase II trial of single-agent dasatinib, five out of six metastatic
melanoma patients with objective tumour-size reductions had
elevated caveolin-1 expression levels before treatment (Jilaveanu
et al, 2011).
Preliminary data suggest that c-Kit inhibitors, including
dasatinib, are highly active in c-Kit mutant melanoma (Lutzky
et al, 2008; Carvajal et al, 2009, 2011; Woodman et al, 2009;
Handolias et al, 2010; Guo et al, 2011), and dasatinib is currently
in phase II testing in patients with solar, mucosal, and acral
melanoma (‘Dasatinib in Advanced Mucosal, Acral, or Solar
Melanoma,’ ClinicalTrials.gov, no date). However, in the current
study, none of the genotyped patients who benefitted clinically
harboured c-Kit mutations.
In summary, the combination of dacarbazine and dasatinib is
well tolerated at clinically relevant dose levels. Dacarbazine dose at
800 mg m
2
combined with 70-mg dasatinib twice daily warrants
further evaluation in the context of a phase II clinical trial in
advanced melanoma, and this trial could further evaluate
candidate biomarkers for response. These biomarkers, if validated,
may help to identify the optimal target population for treatment
with dacarbazine and dasatinib in combination.
ACKNOWLEDGEMENTS
Research support for this trial was provided by Bristol-Myers-
Squibb.
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Dacarbazine with dasatinib phase I trial in melanoma
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  • Source
    • "Analysis of their clinicopathological features does not indicate any particular differences which would facilitate patient selection (SupplementaryTable 8). Preliminary clinical trials of dasatinib in unselected melanoma patients have yielded disappointing results [8, 32]. However, these trials were conducted in unselected patient populations and it is widely accepted that to achieve maximum effectiveness, targeted therapies require biomarker selected patients. "
    [Show abstract] [Hide abstract] ABSTRACT: Dasatinib has anti-proliferative and anti-invasive effects in melanoma cell lines. However clinical trials have shown modest activity for dasatinib in metastatic melanoma. Although dasatinib targets SRC kinase, neither expression nor phosphorylation of SRC appears to predict response to dasatinib. Identification of predictive biomarkers for dasatinib may facilitate selection of melanoma patients who are more likely to respond to dasatinib. We correlated the anti-proliferative effects of dasatinib in 8 melanoma cell lines with expression of a previously identified 6-gene biomarker panel. We examined the relationship between response to dasatinib and expression of each gene at both the mRNA and protein level. Dasatinib inhibited growth in 3 of the 8 cell lines tested. mRNA expression of the panel of 6 biomarkers did not correlate with response, whilst elevated protein expression of ANXA1, CAV-1 and EphA2 correlated significantly with response to dasatinib in the panel of cell lines. Expression of ANXA1, CAV-1 and EphA2 were analysed in 124 melanoma samples by immunohistochemistry. ANXA1 protein was detected in 81 % (97/120) of tumours, CAV-1 in 44 % (54/122) of tumours and EphA2 in 74 % (90/121) of tumours. Thirty one % (35/113) of tumours tested expressed all three markers and 19 % (21/112) had moderate or strong expression of ANXA1, CAV-1 and EphA2. Seventeen percent (19/112) of melanoma samples were positive for SRC kinase expression, combined with high expression of ANXA1, CAV-1 and EphA2. This subgroup may represent a population of melanoma patients who would be more likely to derive clinical benefit from dasatinib treatment.
    Full-text · Article · Mar 2014
  • Source
    • "Indeed, while treatment of melanoma cell lines with the Src inhibitor dasatinib has been shown to inhibit proliferation and invasion [37,38], in some melanoma cell lines it did induce apoptosis [39]. Although clinical responses have been seen in a subset of patients in Phase I and II trials of Dasatinib, biomarkers that predict sensitivity have not yet been identified [40,41] . To validate our findings with E6201 in monolayer culture, we created mouse xenograft models. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Melanoma is the most lethal form of skin cancer, but recent advances in molecularly targeted agents against the Ras/Raf/MAPK pathway demonstrate promise as effective therapies. Despite these advances, resistance remains an issue, as illustrated recently by the clinical experience with vemurafenib. Such acquired resistance appears to be the result of parallel pathway activation, such as PI3K, to overcome single-agent inhibition. In this report, we describe the cytotoxicity and anti-tumour activity of the novel MEK inhibitor, E6201, in a broad panel of melanoma cell lines (n = 31) of known mutational profile in vitro and in vivo. We further test the effectiveness of combining E6201 with an inhibitor of PI3K (LY294002) in overcoming resistance in these cell lines. Results The majority of melanoma cell lines were either sensitive (IC50 < 500 nM, 24/31) or hypersensitive (IC50 < 100 nM, 18/31) to E6201. This sensitivity correlated with wildtype PTEN and mutant BRAF status, whereas mutant RAS and PI3K pathway activation were associated with resistance. Although MEK inhibitors predominantly exert a cytostatic effect, E6201 elicited a potent cytocidal effect on most of the sensitive lines studied, as evidenced by Annexin positivity and cell death ELISA. Conversely, E6201 did not induce cell death in the two resistant melanoma cell lines tested. E6201 inhibited xenograft tumour growth in all four melanoma cell lines studied to varying degrees, but a more pronounced anti-tumour effect was observed for cell lines that previously demonstrated a cytocidal response in vitro. In vitro combination studies of E6201 and LY294002 showed synergism in all six melanoma cell lines tested, as defined by a mean combination index < 1. Conclusions Our data demonstrate that E6201 elicits a predominantly cytocidal effect in vitro and in vivo in melanoma cells of diverse mutational background. Resistance to E6201 was associated with disruption of PTEN and activation of downstream PI3K signalling. In keeping with these data we demonstrate that co-inhibition of MAPK and PI3K is effective in overcoming resistance inherent in melanoma.
    Full-text · Article · Oct 2012 · Molecular Cancer
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    [Show abstract] [Hide abstract] ABSTRACT: Although c-Abl and Arg non-receptor tyrosine kinases are well known for driving leukemia development, their role in solid tumors has not been appreciated until recently. Accumulating evidence now indicates that c-Abl and/or Arg are activated in some solid tumor cell lines via unique mechanisms that do not involve gene mutation/translocation, and c-Abl/Arg activation promotes matrix degradation, invasion, proliferation, tumorigenesis, and/or metastasis, depending on the tumor type. However, some data suggest that c-Abl also may suppress invasion, proliferation, and tumorigenesis in certain cell contexts. Thus, c-Abl/Arg may serve as molecular switches that suppress proliferation and invasion in response to some stimuli (e.g., ephrins) or when inactive/regulated, or as promote invasion and proliferation in response to other signals (e.g., activated growth factor receptors, loss of inhibitor expression), which induce sustained activation. Clearly, more data are required to determine the extent and prevalence of c-Abl/Arg activation in primary tumors and during progression, and additional animal studies are needed to substantiate in vitro findings. Furthermore, c-Abl/Arg inhibitors have been used in numerous solid tumor clinical trials; however, none of these trials were restricted to patients whose tumors expressed highly activated c-Abl/Arg (targeted trial). Targeted trials are critical for determining whether c-Abl/Arg inhibitors can be effective treatment options for patients whose tumors are driven by c-Abl/Arg.
    Preview · Article · May 2012 · Genes & cancer
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