Hypoxia-inducible factor-1alpha modulation in combination with anti-angiogenic therapy.

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Author(s): G. S. Falchook,
J. J. Wheler, N. M. Tannir, A. Naing, E. Jackson, D. Hong, K. N.
Lawhorn, C. Ng, H. Amin, R. Kurzrock; M. D. Anderson Cancer Center,
Houston, TX
Background: HIF-1alpha
mediates adaptive responses to hypoxic conditions induced by
anti-angiogenic therapy. Bortezomib has demonstrated the ability to
inhibit transcriptional activity of HIF-1alpha. We hypothesized that the
addition of bortezomib to bevacizumab would augment response, and we
performed this phase I trial to assess safety, MTD, and correlative
studies of anti-angiogenic activity.
Methods: Patients with
advanced malignancy refractory to standard therapy were eligible.
Cohorts of 6 patients received bevacizumab and bortezomib on a 3-week
cycle, with a stair-step dose escalation design. Pharmacodynamic
assessment included plasma VEGF, VEGFR2, 20S proteasome inhibition,
DCE-MRI, and tumor expression of HIF-1alpha, VEGF, VEGFR2, and
polymorphisms of VEGF and VEGFR2.
Results: 71 patients were treated, and the MTD was identified at the highest dose level (bevacizumab 15 mg/kg, bortezomib 1.3 mg/m2).
Two partial responses were observed in patients with renal cell
carcinoma (RCC) (Total patients with RCC = 6). Minor responses or
stable disease lasting ?4 months was achieved in 8 patients, including
RCC (1), breast (1), leiomyosarcoma (1), nasopharyngeal (2),
hepatocellular (1), neuroendocrine (1), lacrimal gland adenocystic
carcinoma (1). The most common drug-related toxicities observed
included hypertension (36%), fatigue (34%), thrombocytopenia (29%), and
myalgia (19%). 22 patients (31%) experienced no drug-related toxicities
greater than grade 1. 56 patients (79%) experienced no drug-related
toxicities greater than grade 2. One DLT (G5 bleeding) was observed at
the MTD. Plasma VEGF levels demonstrated decreases at 1 and 4 hours
post-infusion, followed by increases to levels above baseline on days
2, 3, and at the end of cycle 1. DCE-MRI analysis demonstrated
decreases in Ktrans on days 2 and 3. Analysis of HIF-1alpha expression in biopsies is underway.
Combination bevacizumab and bortezomib is well-tolerated and has
demonstrated clinical activity in patients with previously treated,
advanced malignancy. Pharmacodynamic assessment with biomarkers and
DCE-MRI suggests that inhibition of angiogenic activity was achieved.
Updated clinical and biomarker data will be presented.