Results of a phase II clinical trial of 6-mercaptopurine (6MP) and methotrexate in patients with BRCA-defective tumours

Corran Roberts, Victoria Y Strauss, Sylwia Kopijasz, Charlie Gourley, Marcia Hall, Ana Montes, Jacinta Abraham, Andrew Clamp, Richard Kennedy, Susana Banerjee, Lisa K Folkes, Michael Stratford, Shibani Nicum, Corran Roberts, Victoria Y Strauss, Sylwia Kopijasz, Charlie Gourley, Marcia Hall, Ana Montes, Jacinta Abraham, Andrew Clamp, Richard Kennedy, Susana Banerjee, Lisa K Folkes, Michael Stratford, Shibani Nicum

Abstract

Background: Tumour cells with BRCA1/2 gene mutations demonstrate increased sensitivity to platinum and poly (ADP-ribose) polymerase (PARP) inhibitors. 6-mercaptopurine (6MP) was found to selectively kill BRCA-defective cells in a xenograft model as effectively as the PARP inhibitor AG014699, even after these cells acquired resistance to a PARP inhibitor or cisplatin.

Methods: This phase II single-arm trial investigated the activity of 6MP 55-75 mg/m2 per day, and methotrexate 15-20 mg/m2 per week in advanced breast or platinum-resistant ovarian cancer patients with a BRCA1/2 germline mutation, who had progressed after ≥1 previous line of chemotherapy. The primary outcome was objective response including stable disease (SD) as an assessment of clinical benefit rate (CBR), at 8 weeks, by RECIST v1.1. Secondary outcomes included overall survival (OS) and progression-free survival (PFS).

Results: In total, 67 evaluable patients were recruited; 55 ovarian and 11 breast cancer patients. In total, 21 patients had SD (31%), one had a partial response (1.5%); CBR was 33% at 8 weeks. In total, 12/67 patients (18%) had SD at 16 weeks. In total, five ovarian cancer patients had SD for over 200 days. Median OS was 10.3 months (95% CI 6.9-14.5), median PFS 1.9 months (1.7-2.8).

Conclusions: The overall activity of 6MP and methotrexate in these patients was low; however, there was a small group of patients who appeared to derive longer-term clinical benefit.

Trial registration: NCT01432145 http://www.ClinicalTrials.gov.

Conflict of interest statement

S.N. has received honoraria from AstraZeneca, Tesaro, Clovis and Roche and has provided consultancy for AstraZeneca, Clovis, Tesaro and Roch, and has received research funding from AstraZeneca. C.G. has received honoraria from AstraZeneca, Tesaro, Cor2Ed and Medscape; has provided consultancy for AstraZeneca, Clovis, Nucana, Tesaro, Roche, Foundation One and Cor2Ed; his institution receives research funding from AstraZeneca, Aprea AB, Nucana and Tesaro. R.K. receives payment as medical director for Almac Diagnostics. J.A. has received honorarium in the past 24 months, which has included travel expenses for advisory roles from Novartis and Genomic Health. S.B. has received research funding from Astrazeneca and has served on advisory boards for Astrazeneca, Tesaro and Clovis. All other authors jointly declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
CONSORT flow diagram.
Fig. 2
Fig. 2
Overall survival (a) and progression-free survival (b).

References

    1. Ferlay, J. S. I, Ervik, M, Dikshit, R, Eser, S, Mathers, C., Rebelo, M. et al. Rebelo M et al. GLOBOCAN2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11, Lyon, France: International Agency for Research on Cancer. (2013).
    1. Eisenhauer EA. Real-world evidence in the treatment of ovarian cancer. Ann. Oncol. 2017;28:viii61–viii65.
    1. Risch HA, McLaughlin JR, Cole DE, Rosen B, Bradley L, Kwan E, et al. Prevalence and penetrance of germline BRCA1 and BRCA2 mutations in a population series of 649 women with ovarian cancer. Am. J. Hum. Genet. 2001;68:700–710.
    1. Alsop K, Fereday S, Meldrum C, deFazio A, Emmanuel C, George J, et al. BRCA mutation frequency and patterns of treatment response in BRCA mutation-positive women with ovarian cancer: a report from the Australian Ovarian Cancer Study Group. J. Clin. Oncol. 2012;30:2654–2663.
    1. McPherson K, Steel CM, Dixon JM. ABC of breast diseases. Breast cancer-epidemiology, risk factors, and genetics. BMJ. 2000;321:624–628.
    1. Easton D, Ford D, Peto J. Inherited susceptibility to breast cancer. Cancer Surv. 1993;18:95–113.
    1. Oesterreich S, Fuqua SA. Tumor suppressor genes in breast cancer. Endocr. Relat. Cancer. 1999;6:405–419.
    1. Lakhani SR, Reis-Filho JS, Fulford L, Penault-Llorca F, van der Vijver M, Parry S, et al. Prediction of BRCA1 status in patients with breast cancer using estrogen receptor and basal phenotype. Clin. Cancer Res. 2005;11:5175–5180.
    1. Bryant HE, Schultz N, Thomas HD, Parker KM, Flower D, Lopez E, et al. Specific killing of BRCA2-deficient tumours with inhibitors of poly(ADP-ribose) polymerase. Nature. 2005;434:913–917.
    1. Farmer H, McCabe N, Lord CJ, Tutt ANJ, Johnson DA, Richardson TB, et al. Targeting the DNA repair defect in BRCA mutant cells as a therapeutic strategy. Nature. 2005;434:917–921.
    1. Murai J, Huang S-yN, Das BB, Renaud A, Zhang Y, Doroshow JH, et al. Trapping of PARP1 and PARP2 by Clinical PARP Inhibitors. Cancer Res. 2012;72:5588–5599.
    1. Polak P, Kim J, Braunstein LZ, Karlic R, Haradhavala NJ, Tiao G, et al. A mutational signature reveals alterations underlying deficient homologous recombination repair in breast cancer. Nat. Genet. 2017;49:1476.
    1. FDA. Lynparza (olaparib) tablets, for oral use: prescribing information. (2018).
    1. Mirza MR, Monk BJ, Herrstedt J, Oza AM, Mahner S, Redondo A, et al. Niraparib maintenance therapy in platinum-sensitive, recurrent ovarian cancer. N. Engl. J. Med. 2016;375:2154–2164.
    1. Coleman RL, Oza AM, Lorusso D, Aghajanian C, Oaknin A, Dean A, et al. Rucaparib maintenance treatment for recurrent ovarian carcinoma after response to platinum therapy (ARIEL3): a randomised, double-blind, placebo-controlled, phase 3 trial. The Lancet. 2017;390:1949–1961.
    1. Moore K, Colombo N, Scambia G, Kim B-G, Oaknin A, Friedlander M, et al. Maintenance olaparib in patients with newly diagnosed advanced ovarian cancer. N. Engl. J. Med. 2018;379:2495–2505.
    1. Robson M, Im S-A, Senkus E, Xu B, Domchek SM, Masuda N, et al. Olaparib for metastatic breast cancer in patients with a germline BRCA mutation. N. Engl. J. Med. 2017;377:523–533.
    1. Barber LJ, Sandhu S, Chen L, Campbell J, Kozarewa I, Fenwick K, et al. Secondary mutations in BRCA2 associated with clinical resistance to a PARP inhibitor. J. Pathol. 2013;229:422–429.
    1. Makvandi M, Xu K, Lieberman BP, Anderson R-C, Effron SS, Winters HD, et al. A radiotracer strategy to quantify PARP-1 expression in vivo provides a biomarker that can enable patient selection for PARP Inhibitor Therapy. Cancer Res. 2016;76:4516.
    1. Ray Chaudhuri A, Callen E, Ding X, Gogola E, Duarte AA, Lee J-E, et al. Replication fork stability confers chemoresistance in BRCA-deficient cells. Nature. 2016;535:382.
    1. Issaeva N, Thomas HD, Djureinovic T, Jaspers JE, Stoimenov I, Kyle S, et al. 6-thioguanine selectively kills BRCA2-defective tumors and overcomes PARP inhibitor resistance. Cancer Res. 2010;70:6268–6276.
    1. Coulthard S, Hogarth L. The thiopurines: An update. Investigational New Drugs. 2005;23:523–532.
    1. Swann PF, Waters TR, Moulton DC, Xu YZ, Zheng Q, Edwards M, et al. Role of postreplicative DNA mismatch repair in the cytotoxic action of thioguanine. Science. 1996;273:1109–1111.
    1. Griffin S, Branch P, Xu YZ, Karran P. DNA mismatch binding and incision at modified guanine bases by extracts of mammalian cells: implications for tolerance to DNA methylation damage. Biochemistry. 1994;33:4787–4793.
    1. Waters TR, Swann PF. Cytotoxic mechanism of 6-thioguanine: hMutSalpha, the human mismatch binding heterodimer, binds to DNA containing S6-methylthioguanine. Biochemistry. 1997;36:2501–2506.
    1. Yan T, Berry SE, Desai AB, Kinsella TJ. DNA mismatch repair (MMR) mediates 6-thioguanine genotoxicity by introducing single-strand breaks to signal a G2-M arrest in MMR-proficient RKO cells. Clin. Cancer Res. 2003;9:2327–2334.
    1. Lennard L. The clinical pharmacology of 6-mercaptopurine. Eur. J. Clin. Pharmacol. 1992;43:329–339.
    1. Relling MV, Hancock ML, Rivera GK, Sandlund JT, Ribeiro RC, Krynetski EY, et al. Mercaptopurine therapy intolerance and heterozygosity at the thiopurine S-methyltransferase gene locus. J Natl Cancer Inst. 1999;91:2001–2008.
    1. Dean L. Mercaptopurine Therapy and TPMT Genotype (eds Pratt V., McLeod H., Dean L., Malheiro A. & Rubinstein W.). (Medical Genetics Summaries, Bethesda, MD, 2012).
    1. Bokkerink JP, De Abreu RA, Bakker MA, Hulscher TW, van Baal JM, Schretlen ED, et al. Effects of methotrexate on purine and pyrimidine metabolism and cell-kinetic parameters in human malignant lymphoblasts of different lineages. Biochem. Pharmacol. 1988;37:2329–2338.
    1. Martin SA, McCarthy A, Barber LJ, Burgess DJ, Parry S, Lord CJ, et al. Methotrexate induces oxidative DNA damage and is selectively lethal to tumour cells with defects in the DNA mismatch repair gene MSH2. EMBO Mol. Med. 2009;1:323–337.
    1. Nicum S, Roberts C, Boyle L, Kopijasz S, Gourley C, Hall M, et al. A phase II clinical trial of 6-mercaptopurine (6MP) and methotrexate in patients with BRCA defective tumours: a study protocol. BMC Cancer. 2014;14:983.
    1. Jung SH, Carey M, Kim KM. Graphical search for two-stage designs for phase II clinical trials. Control Clin. Trials. 2001;22:367–372.
    1. Jung SH, Lee T, Kim K, George SL. Admissible two-stage designs for phase II cancer clinical trials. Stat Med. 2004;23:561–569.
    1. Hawwa AF, Millership JS, Collier PS, McElnay JC. Development and validation of an HPLC method for the rapid and simultaneous determination of 6-mercaptopurine and four of its metabolites in plasma and red blood cells. J. Pharm. Biomed. Anal. 2009;49:401–409.
    1. Kaufman B, Shapira-Frommer R, Schmutzler RK, Audeh MW, Friedlander M, Balmana J, et al. Olaparib monotherapy in patients with advanced cancer and a germline BRCA1/2 mutation. J. Clin. Oncol. 2015;33:244–250.
    1. McNeish IA, Ledermann JA, Webber L, James L, Kaye SB, Hall M, et al. A randomised, placebo-controlled trial of weekly paclitaxel and saracatinib (AZD0530) in platinum-resistant ovarian, fallopian tube or primary peritoneal cancerdagger. Ann. Oncol. 2014;25:1988–1995.
    1. Tan DS, Yap TA, Hutka M, Roxburgh P, Ang J, Banerjee S, et al. Implications of BRCA1 and BRCA2 mutations for the efficacy of paclitaxel monotherapy in advanced ovarian cancer. Eu.r J. Cancer. 2013;49:1246–1253.
    1. Kaye SB, Lubinski J, Matulonis U, Ang JE, Gourley C, Karlan BY, et al. Phase II, open-label, randomized, multicenter study comparing the efficacy and safety of olaparib, a poly (ADP-ribose) polymerase inhibitor, and pegylated liposomal doxorubicin in patients with BRCA1 or BRCA2 mutations and recurrent ovarian cancer. J. Clin. Oncol. 2012;30:372–379.
    1. Lilleyman JS, Lennard L. Mercaptopurine metabolism and risk of relapse in childhood lymphoblastic leukaemia. Lancet. 1994;343:1188–1190.
    1. Hawwa AF, Collier PS, Millership JS, McCarthy A, Dempsey S, Cairns C, et al. Population pharmacokinetic and pharmacogenetic analysis of 6-mercaptopurine in paediatric patients with acute lymphoblastic leukaemia. Br. J. Clin. Pharmacol. 2008;66:826–837.
    1. Cheok MH, Evans WE. Acute lymphoblastic leukaemia: a model for the pharmacogenomics of cancer therapy. Nat Rev Cancer. 2006;6:117–129.
    1. Colombel JF, Ferrari N, Debuysere H, Marteau P, Gendre JP, Bonaz B, et al. Genotypic analysis of thiopurine S-methyltransferase in patients with Crohn’s disease and severe myelosuppression during azathioprine therapy. Gastroenterology. 2000;118:1025–1030.
    1. Lennard L, Welch J, Lilleyman JS. Mercaptopurine in childhood leukaemia: the effects of dose escalation on thioguanine nucleotide metabolites. Br. J. Clin. Pharmacol. 1996;42:525–527.
    1. Dervieux T, Brenner TL, Hon YY, Zhou Y, Hancock ML, Sandlund JT, et al. De novo purine synthesis inhibition and antileukemic effects of mercaptopurine alone or in combination with methotrexate in vivo. Blood. 2002;100:1240–1247.
    1. McAlpine JN, Porter H, Kobel M, Nelson BH, Prentice LM, Kalloger SE, et al. BRCA1 and BRCA2 mutations correlate with TP53 abnormalities and presence of immune cell infiltrates in ovarian high-grade serous carcinoma. Mod. Pathol. 2012;25:740–750.
    1. Strickland KC, Howitt BE, Shukla SA, Rodig S, Ritterhouse LL, Liu JF, et al. Association and prognostic significance of BRCA1/2-mutation status with neoantigen load, number of tumor-infiltrating lymphocytes and expression of PD-1/PD-L1 in high grade serous ovarian cancer. Oncotarget. 2016;7:13587–13598.
    1. Nolan, E., Savas, P., Policheni, A. N., Darcy, P. K., Vaillant, F., Mintoff, C. P., et al. Combined immune checkpoint blockade as a therapeutic strategy for BRCA1-mutated breast cancer. Sci. Transl. Med.9, pii: eaal4922 (2017).

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe