TY - JOUR
T1 - Increased 9-aminocamptothecin dose requirements in patients on anticonvulsants
AU - Grossman, Stuart A.
AU - Hochberg, Fred
AU - Fisher, Joy
AU - Chen, T. L.
AU - Kim, Lyndon
AU - Gregory, Rebecca
AU - Grochow, Louise B.
AU - Piantadosi, Steven
N1 - Funding Information:
This work was supported by the following grants from the National Cancer Institute: 5UO1CA62474, 5UO1CA62475, 5UO1CA62406, 5UO1CA62432, 5UO1CA62419, 5UO1CA62430, 5UO1CA62473 Participating NABTT institutions and investigators: Brown University (P. Calabresi, M. Glantz), Columbia University (M. Fetell), Henry Ford Hospital (T. Mikkelsen), Johns Hopkins University (S. Grossman), Massachusetts General Hospital (F. Hochberg, L. Kim), H. Lee Mott Cancer Center (S. Phuphanich), Northwestern University (J. Rozental), and Wake ForestUniversity (G. Lesser) S.A. Grossman (&) á F. Hochberg á J. Fisher á T.-L. Chen á L. Kim á R. Gregory á L.B. Grochow á S. Piantadosi The Central Operations Oce, The NABTT CNS Consortium, The Johns Hopkins Oncology Center, 600 North Wolfe Street, Baltimore, MD 21287, USA Tel. +1-410-955-8837; Fax +1-410-955-0125; E-mail grossman@welchlink.welch.jhu.edu
PY - 1998
Y1 - 1998
N2 - Background: High grade astrocytomas remain uniformly fatal despite aggressive surgery and radiotherapy. As existing chemotherapeutic agents are of limited benefit, clinical trials are underway to screen new drugs, such as 9-aminocamptothecin (9-AC), for activity in high grade astrocytomas. Purpose: This study was designed to estimate the efficacy of 9-AC in patients with newly diagnosed glioblastoma multiforme and recurrent high grade astrocytomas. The planned dose of 9-AC for this trial was 850 μg/m2 per 24 h as a 72-h continuous intravenous infusion every 2 weeks. This was the maximum tolerated dose (MTD) on this schedule in multiple phase I studies in patients with systemic malignancies. However, we found this dose subtherapeutic in our patient population. As a result, the purpose of the study was altered to determine the MTD. Methods: A group of 32 patients were studied using 850 μg/m2 per 24 h with a provision to escalate to 1000 μg/m2 per 24 h if the first three cycles of 9-AC were without significant hematologic toxicity. Once it was determined that myelosuppression did not occur in patients on anticonvulsants, dose escalations were initiated using the continual reassessment method. Dose escalations were conducted independently in newly diagnosed and recurrent patients and in those taking and not taking hepatic enzyme-inducing anticonvulsants. Pharmacologic studies were conducted during the first cycle of 9-AC. Toxicity was determined using the NCI common toxicity criteria and efficacy was assessed using serial volumetric brain scans. Results: 9-AC was administered to 59 patients, 31 with newly diagnosed glioblastoma multiforme and 28 with recurrent high grade astrocytomas. No grade III-IV myelosuppression was noted in the 29 patients (128 cycles) on phenytoin, carbamazepine, phenobarbital, and/or valproic acid who received 850 μg/m2 per 24 h. In contrast, two of three patients (five cycles) who were not taking anticonvulsants developed grade IV myelosuppression. Steady-state total 9-AC plasma levels were lower in patients on anticonvulsants (median 25.3 nM) than in patients who were not taking anticonvulsants (median 76.5 nM). Dose escalations performed in 27 additional patients determined the MTD in patients taking anticonvulsants to be 1776 μg/m2 per 24 h for patients with newly diagnosed tumors and 1611 μg/m2 per 24 h for patients with recurrent disease. Conclusions: We describe a new and unexpected drug interaction between 9-AC and anticonvulsants. This is similar to recent findings with paclitaxel, and suggests that higher than 'usual' doses of some chemotherapeutic agents are required in patients on anticonvulsants. Prospectively defined dose escalations and pharmacologic studies are essential for the careful evaluation of new chemotherapeutic agents in patients with brain tumors.
AB - Background: High grade astrocytomas remain uniformly fatal despite aggressive surgery and radiotherapy. As existing chemotherapeutic agents are of limited benefit, clinical trials are underway to screen new drugs, such as 9-aminocamptothecin (9-AC), for activity in high grade astrocytomas. Purpose: This study was designed to estimate the efficacy of 9-AC in patients with newly diagnosed glioblastoma multiforme and recurrent high grade astrocytomas. The planned dose of 9-AC for this trial was 850 μg/m2 per 24 h as a 72-h continuous intravenous infusion every 2 weeks. This was the maximum tolerated dose (MTD) on this schedule in multiple phase I studies in patients with systemic malignancies. However, we found this dose subtherapeutic in our patient population. As a result, the purpose of the study was altered to determine the MTD. Methods: A group of 32 patients were studied using 850 μg/m2 per 24 h with a provision to escalate to 1000 μg/m2 per 24 h if the first three cycles of 9-AC were without significant hematologic toxicity. Once it was determined that myelosuppression did not occur in patients on anticonvulsants, dose escalations were initiated using the continual reassessment method. Dose escalations were conducted independently in newly diagnosed and recurrent patients and in those taking and not taking hepatic enzyme-inducing anticonvulsants. Pharmacologic studies were conducted during the first cycle of 9-AC. Toxicity was determined using the NCI common toxicity criteria and efficacy was assessed using serial volumetric brain scans. Results: 9-AC was administered to 59 patients, 31 with newly diagnosed glioblastoma multiforme and 28 with recurrent high grade astrocytomas. No grade III-IV myelosuppression was noted in the 29 patients (128 cycles) on phenytoin, carbamazepine, phenobarbital, and/or valproic acid who received 850 μg/m2 per 24 h. In contrast, two of three patients (five cycles) who were not taking anticonvulsants developed grade IV myelosuppression. Steady-state total 9-AC plasma levels were lower in patients on anticonvulsants (median 25.3 nM) than in patients who were not taking anticonvulsants (median 76.5 nM). Dose escalations performed in 27 additional patients determined the MTD in patients taking anticonvulsants to be 1776 μg/m2 per 24 h for patients with newly diagnosed tumors and 1611 μg/m2 per 24 h for patients with recurrent disease. Conclusions: We describe a new and unexpected drug interaction between 9-AC and anticonvulsants. This is similar to recent findings with paclitaxel, and suggests that higher than 'usual' doses of some chemotherapeutic agents are required in patients on anticonvulsants. Prospectively defined dose escalations and pharmacologic studies are essential for the careful evaluation of new chemotherapeutic agents in patients with brain tumors.
KW - 9- Aminocamptothecin
KW - Anticonvulsants
KW - Glioblastoma multiforme
KW - High grade astrocytoma
KW - Primary brain tumor
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U2 - 10.1007/s002800050794
DO - 10.1007/s002800050794
M3 - Article
C2 - 9654111
AN - SCOPUS:0031832859
SN - 0344-5704
VL - 42
SP - 118
EP - 126
JO - Cancer Chemotherapy and Pharmacology
JF - Cancer Chemotherapy and Pharmacology
IS - 2
ER -