Phase 1 study of everolimus and low-dose oral cyclophosphamide in patients with metastatic renal cell carcinoma

Charlotte M Huijts, Inge M Werter, Sinéad M Lougheed, Ruben S Goedegebuure, Carla M van Herpen, Paul Hamberg, Metin Tascilar, John B Haanen, Henk M Verheul, Tanja D de Gruijl, Hans J van der Vliet, Dutch WIN-O Consortium, Charlotte M Huijts, Inge M Werter, Sinéad M Lougheed, Ruben S Goedegebuure, Carla M van Herpen, Paul Hamberg, Metin Tascilar, John B Haanen, Henk M Verheul, Tanja D de Gruijl, Hans J van der Vliet, Dutch WIN-O Consortium

Abstract

mTOR inhibitors are frequently used in the treatment of metastatic renal cell cancer (mRCC). mTOR regulates cell growth, proliferation, angiogenesis, and survival, and additionally plays an important role in immune regulation. Since mTOR inhibitors were shown to benefit immunosuppressive regulatory T-cell (Treg) expansion, this might suppress antitumor immune responses. Metronomic cyclophosphamide (CTX) was shown to selectively deplete Tregs. This study was, therefore, designed to determine the optimal dosage and schedule of CTX when combined with everolimus to prevent this potentially detrimental Treg expansion. In this national multi-center phase I study, patients with mRCC progressive on first line anti-angiogenic therapy received 10 mg everolimus once daily and were enrolled into cohorts with different CTX dosages and schedules. Besides immune monitoring, adverse events and survival data were monitored. 40 patients, 39 evaluable, were treated with different doses and schedules of CTX. Combined with 10 mg everolimus once daily, the optimal Treg depleting dose and schedule of CTX was 50 mg CTX once daily. 23 (59%) patients experienced one or more treatment-related ≥ grade 3 toxicity, mostly fatigue, laboratory abnormalities and pneumonitis. The majority of the patients achieved stable disease, two patients a partial response. Median PFS of all cohorts was 3.5 months. In conclusion, the optimal Treg depleting dose and schedule of CTX, when combined with everolimus, is 50 mg once daily. This combination leads to acceptable adverse events in comparison with everolimus alone. Currently, the here selected combination is being evaluated in a phase II clinical trial. TRIAL REGISTRATION: NCT01462214.

Keywords: Cyclophosphamide; Everolimus; Tregs; mTOR.

Conflict of interest statement

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

ClinicalTrials.gov Identifier NCT01462214, Netherlands Trial Register number NTR3085. The study was conducted in accordance with the Declaration of Helsinki and consistent with International Conference on Harmonization (ICH) Guidelines for Good Clinical Practice. The Medical Ethical Committee of the VU University Medical Center, Amsterdam, the Netherlands and the Central Committee on Research Involving Human Subjects (CCMO) approved the study protocol.

Informed consent

All patients gave written informed consent.

Figures

Fig. 1
Fig. 1
Effect of different dosages and administration schedules of CTX when combined with a fixed dose of 10 mg everolimus on the frequency of Tregs. a Relative percentages of Tregs within CD4+ T cells were determined in freshly isolated PBMC from patients treated with different dosages and schedules of CTX, combined with a fixed dose of everolimus at baseline and subsequently 2, 4, and 8 weeks after start of treatment. p value indicated with asterisk; *p ≤ 0.05, **p ≤ 0.01, ***p ≤ 0.001, xp = 0.07. b Relative percentages of Tregs within CD4+ T cells are shown for cohort 2 combined with the expansion cohort. Patients were treated with 50 mg CTX once daily, combined with 10 mg everolimus once daily. Means ± SEM are shown; p value indicated with asterisk; *p ≤ 0.05, **p ≤ 0.01, ****p ≤ 0.0001
Fig. 2
Fig. 2
Effect of different dosages and administration schedules of CTX when combined with a fixed dose of 10 mg everolimus on absolute Treg numbers. a Relative percentages of absolute Treg numbers were determined in freshly isolated PBMC from patients treated with different dosages and schedules of CTX, combined with a fixed dose of everolimus at baseline and subsequently 2, 4, and 8 weeks after start of treatment. p value indicated with asterisk, *p ≤ 0.05. b Relative percentages of absolute Treg numbers are shown for cohort 2 combined with the expansion cohort. Patients were treated with 50 mg CTX once daily, combined with 10 mg everolimus once daily. Means ± SEM are shown; p value indicated with asterisk; *p ≤ 0.05
Fig. 3
Fig. 3
Clinical outcome. a Best clinical response for the total study population. b Best clinical response shown per cohort. Partial remission (PR) is shown in black, stable disease (SD) in grey and progressive disease (PD) in light grey
Fig. 4
Fig. 4
Kaplan–Meier curves for PFS per cohort, compared to the total patient group

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