GESTIRE LA TOSSICITÀ

Teresa TroianiMD, PHD

U.O.C. OncoEmatologiaSeconda Università degli Studi di Napoli

Wilson, P. M. et al. Nat. Rev. Clin. Oncol. 2014

Wilson, P. M. et al. Nat. Rev. Clin. Oncol. 2014

Wilson, P. M. et al. Nat. Rev. Clin. Oncol. 2014

5-FU/Capecitabine vs TAS-102

Peters GJ, Nucleotides and Nucleic Acids (2014)

Wilson, P. M. et al. Nat. Rev. Clin. Oncol. 2014

Wilson, P. M. et al. Nat. Rev. Clin. Oncol. 2014

80% of 5FU catabolism is mediated by DPD (dihydropyrimidinedehydrogenase)

The primary catabolite is fluoro-β-alanine, that contributes to:

Neurotoxic events +Cardiotoxic events ++Hand and foot syndrome +++

Phosphorylation of 5FU leads to the production of FUMP, thatcontributes to:Gastrointestinal events +++

S1 , an other oral FP, combining tegafur (a 5FU pro drug), gimeracil ( CDHP , DPD inhibitor) and oteracil potassium (OPRT inhibitor), shows reduced incidence of HFS and GI events

5FU Toxicities

Adverse reactions of any grade that occurred in >15% (bars 1) or ≥20% (bars 2) of patients treated with capecitabine or the combination 5-fluorouracil/ leucovorin. *Statistically significant difference (p < 0.00001 for bars 1 or p < 0.0002 for bars 2).

• Van Cutsem et al. Oral capecitabine compared with intravenous fluorouracil plus leucovorin in patients with metastatic colorectal cancer: results of a large phase III study. J Clin Oncol 2001

• Twelves C et al. Capecitabine (XelodaTM) improves medical resource use compared with 5-fluorouracil plus leucovorin in a phase III trial conducted in patients with advanced colorectal carcinoma. Eur J Cancer 2001

• Hoff PM al. Comparison of oral capecitabine versus intravenous fluorouracil plus leucovorin as first-line treatment in 605 patients with metastatic col- orectal cancer: results of a randomized phase III study. J Clin Oncol 2001

Malet Martino et al. The Oncologist 2002

Most common treatment-related

clinical adverse events (all grades)

Diarrhoea Stomatitis Hand-foot Nausea Vomiting Alopecia Fatigue

syndrome

Pati

en

ts (

%)

Xeloda (n=596)

5-FU/LV (n=593)

*

*

*

*

*

*p<0.001Hoff PM et al. Oncologist 2001;6(Suppl. 4):3–11

100

80

60

40

20

0

60%

50%

Neutropenia:

Xeloda:2.2% FU/LV:21.2%

Most common grade 3/4 treatment-related

adverse events

Xeloda (n=596)

5-FU/LV (n=593)

Pati

en

ts (

%)

Diarrhoea Stomatitis Hand-foot Nausea Vomiting Neutropenic

syndrome fever/sepsis

*

*

*

*p<0.05

18

16

14

12

10

8

6

4

2

0

Twelves C. Eur J Cancer 2002;38(Suppl. 2):S15–S20

14%

12%

0.2%

3.4%

In an assessment of TAS-102 group after two cycles:• 53% had a delay of 4 days or more in beginning their next

cycle owing to toxicity• the delay in approximately half of this subgroup extended

for 8 days or more.

In the TAS-102 group a total of 73 patients (14%) required dose reductions:• 53 patients [10%] having a single dose reduction• 18 [3%] having two reductions• 2 [<1%] having three reductions)

Adverse events resulted in the withdrawal of 4% of the patients receiving TAS-102 and 2% of the patients receiving placebo.

In TAS-102 group:• 38% G≥3 neutropenia • 18% G≥3 anemia• 5% G≥3 thrombocytopenia

• 2% G≥3 nausea • 2% G≥3 vomiting • 3% G≥3 diarrhea

• 7% alopecia

no clinically meaningful differences were noted with respect to the development of serious hepatic or renal dysfunction, anorexia, stomatitis, hand–foot syndrome, or cardiac events.

Mayer RJ et al. NEJM 2015

Xeloda:DiarrheaAny Grade Grade>3

50% 12%

Xeloda:NeutropeniaAny Grade NF2.2% 0.2%

In an assessment of TAS-102 group after two cycles:• 53% had a delay of 4 days or more in beginning their next

cycle owing to toxicity• the delay in approximately half of this subgroup extended

for 8 days or more.

In the TAS-102 group a total of 73 patients (14%) required dose reductions:• 53 patients [10%] having a single dose reduction• 18 [3%] having two reductions• 2 [<1%] having three reductions)

Adverse events resulted in the withdrawal of 4% of the patients receiving TAS-102 and 2% of the patients receiving placebo.

In TAS-102 group:• 38% G≥3 neutropenia • 18% G≥3 anemia• 5% G≥3 thrombocytopenia

• 2% G≥3 nausea • 2% G≥3 vomiting • 3% diarrhea

• 7% alopecia

no clinically meaningful differences were noted with respect to the development of serious hepatic or renal dysfunction, anorexia, stomatitis, hand–foot syndrome, or cardiac events.

Mayer RJ et al. NEJM 2015

Supportive treatment for hematologic toxicitiesin RECOURSE trial

• Of 533 pts in the TAS-102 group, 50 (9.4%) received G-CSF vs 0/265 in the pbo group

• more TAS-102 pts also received antianemia products such as epoetin (25 [4.7%] TAS-102 vs 2 [0.3%] pbo).

• The incidence of hematologic toxicities that resulted in dose reductions/delays was 43.0% vs 1.1% for all grades and 29.6% vs 0.8% for Grade ≥ 3, TAS-102 vs pbo, respectively.

• The incidence of febrile neutropenia and hospitalization due to febrile neutropenia was 2.4%.

Conclusions: The incidence of hematologic toxicity and consequent use of supportive therapies and use of dose reductions/delays were higher in the TAS-102 group vs pbo group. Low incidence of febrile neutropenia may be related to use of G-CSF, but further analyses to ascertain the role of G-CSF are ongoing. No specific proposal for hematologic toxicity management beyond standard supportive therapies is

recommended as institutional or national guidelines are well established.

Meyer et al. E15021 ASCO 2016

NEUTROPENIA FEBBRILE

Profilassi primaria

E’ indicata già dal primo ciclo di chemioterapia per prevenire le complicanze della neutropenia e per mantenere la dose intensity nei trattamenti curativi

NEUTROPENIA FEBBRILE

Profilassi secondaria

• E' raccomandata per i pazienti che abbiano avuto un pregresso episodio di NF e per i pazienti per i quali il mantenimento di una corretta intensità di dose (dose dei farmaci e intervallo dei cicli) può influenzare la sopravvivenza libera da malattia o globale (Livello di evidenza 4). In caso contrario, la prima opzione terapeutica è rappresentata da una riduzione della dose o da un posticipo temporale

NEUTROPENIA FEBBRILE

Utilizzo terapeutico del G-CSF

Yoshino T et al. Clinical colorectal Cancer 2016

Yoshino T et al. Clinical colorectal Cancer 2016

• This was a postmarketing surveillance study; ADR collection was dependent upon spontaneousreporting.

• The number of TAS-102 prescriptions and patientstreated with TAS-102 during the study period are only estimated on the basis of a preregistrationsystem, in which registration forms were faxed to the Patient Registration Center from the institutebefore drug administration

• Because the preregistration by fax was notmandatory, the precise number of patients couldnot be determined.

• 370 total ADRs were reported

Yoshino T et al. Clinical colorectal Cancer 2016

Serious neutropenia and FN tended to occur from days 15 to 21 in the first treatment cycle in 12 (75.0%) of 16 patients.

14/16 patients were confirmed to have recovered or were recovering; among them, 64.2% (9 patients) recovered or were recovering around day 6 afteronset (median, 7 days; range, 5-20 days). A detailed investigation report was available in 11 patients: granulocyte-colony stimulating factor (G-CSF) was given to 8 patients (72.7%) and prophylactic and/or therapeutic antibiotics to 10 patients (90.9%). Death due to infection induced by serious neutropenia was observed in 2 patients—1 experienced FN on day 15 and the other experienced it on day 18.In 36/52 patients, nonserious neutropenia tended to occur from days 22 to 28 in the first treatment cycle; All patients had recovered or wererecovering with appropriate therapeutic measures. In 23 of the 52 patients (44.2%), neutropenia had resolved or was resolving at around day 7 afterthe onset (median, 10 days; range, 2-89 days).

Yoshino T et al. Clinical colorectal Cancer 2016

Three ADRs of cardiac disorders were observed in 2 patients• 1 patient with concurrent cardiac ischemia developed

decreased left ventricular function• 1 patient with a history of myocardial infarction and

complications of hypertension, hyperlipidemia and diabetesmellitus, experienced congestive heart failure and atrialfibrillation after receiving TAS- 102

Yoshino T et al. Clinical colorectal Cancer 2016

Interstitial lung disease was observed in 7 patients, including 3 patients with a history of ILD related to previous treatment. All patients

were confirmed to have recovered or recovering.

• Median time to onset was 51 days (range, 22-91 days)

• Median time to recovery was 10 days (range, 7-39 days)

Yoshino T et al. Clinical colorectal Cancer 2016

Petrelli et al. BMC Cancer 2016

Petrelli et al. BMC Cancer 2016

• In phase I studies, no cardiotoxic events were reported, including 3 single agent TAS 102 trials and a phase I study of a combination of TAS 102 with a fixed dose of irinotecan (121 patients overall).

• In the phase II trials comparing TAS 102 (at the labeled dose) with placebo, 112 patients were randomized but no cardiotoxic events werereported.

• In the phase III study by Mayer et al. n = 3 and n = 2 cardiac events(cardiac ischemia) were recorded in the experimental and control armsrespectively, with no rate of cardiac arrhythmia observed. The rate of cardiotoxicity is 0.5 %

• That represents from 2 to 40-fold numerically less frequent of thatreported with 5FU in literature.

A potential limitation of our observation is that the patients who hadcardiotoxicity during previous treatments might have been excluded from TAS102 trials, which enrolled patients heavely pretreated with many previouslines of therapies.

Petrelli et al. BMC Cancer 2016

• The exact pathophysiology of these events is not well known, but a cardiacvasospasm seems the main events associated with cardiotoxicity.

• The role of the 5FU metabolites: in particular 5FU is catabolized to alpha-fluoro-beta-alanine (FBAL) and subsequently to fluoroacetate, the latter suspect inparticular as a cardiotoxic substance.

• Recently, Italian authors analyzed human cardiomyocytes and endothelial cells toevaluate the effect of 5FU. They observed autophagic features with reactiveoxygen species (ROS) elevation as an endothelial response and induction of asenescent phenotype on both cell types treated with 5FU . By these data andowing to the relative mis- understanding of exact mechanisms involved in thecardiotoxicity of 5FU, there is a rationale for using different inhibitors ofthymidylate synthase (TS), commonly prescribed in clinical practice, in particular,raltitrexed. Animal studies of myocardium damage after 5FU administrationshowed that multifocal hemorrhages, myofiber necrosis, inflammatory reactionsincluding perivascular involvement, pericarditis, valvulitis and vascular changes,were observed.

Petrelli et al. BMC Cancer 2016

Possible mechanisms of reduced cardio-toxic events in patients treated with TAS 102 :

1. Differential activation of cell death and autophagy. Autophagic features at the ultrastructural andmolecular levels, in particular in 5-FU exposed cardiomyocytes and endothelial cells can beobserved. Conversely, TFT is more potent than 5FU, because it induces higher levels of cell deathand does not elicit an autophagic survival response in the cancer cell lines.

2. Different oncological target (DNA damage and synthesis) for TAS 102 itself compared to 5FU orcapecitabine: TF-TMP (tri-fluorothymidine monophosphate) and TF-TTP (tri-fluorothymidinetriphosphate) vs FdUMP (fluorodeoxyuridine monophosphate) and FdUTP (fluorodeoxyuridinetriphosphate).

3. Different incorporation in tissues. The incorporation of FTD into DNA in tumor tissues issignificantly higher than its incorporation into DNA in normal tissues, thus sparing cardiovasculartissues.

4. Different metabolism. TAS 102 is not catabolized by dihydropyridine dehydrogenase (DPD), that ispredominantly expressed in the liver and inactivates more than 80 % of administered 5FU, withconsequently reduced formation of cardiotoxyc metabolits eg. FBAL and F-citrate. F-citrate inhibitsthe Krebs cycle by inhibition of aconitase, limiting the cellular production of adenosinetriphosphate (ATP). Fluoroacetate is known to be highly cardiotoxic and neurotoxic.

Petrelli et al. BMC Cancer 2016

• Drug pharmacokinetics was evaluated using a randomized, single-dose, two-treatment (fed versus fasting), two- period, two-sequence cross-over design, followed by repeated administration.

• 16 patients were given single doses of TAS-102 (35 mg ⁄ m2) in the pharmacokinetic phase and received twice-daily doses of TAS-102 in 28-day cycles in the repeated administration phase for evaluating efficacy and safety.

Yoshino T et al. Cancer Science 2016

• As TAS-102 is given orally, assessment of the effect of food on the pharmacokinetics of its constituents is required.

• The primary objective of this study was to assess the effect of food on the pharmacokinetics of FTD and TPI after a single oraladministration of TAS-102.

• The secondary objective was to investigate the efficacy and safety of repeated TAS-102 administration.

• A high-fat, high-calorie meal was used to evaluate the maximal effect of food intake on pharmacokinetics.

Yoshino T et al. Clinical colorectal Cancer 2016

• Food showed no effect on the area under the curve from 0 to 12 h or 0 h–infinity values of trifluridine followingadministration of TAS-102 under fasting and fed conditions, whereas those of tipiracil hydrochloride decreased byapproximately 40%.

• Maximum concentrations of both drugs decreased by approximately 40%, indicating that food influenced the absorption andbioavailability of trifluridine and tipiracil hydrochloride, respectively.

• During the repeated administration, stable disease was observed in nine patients with rectal, small-cell lung, breast, thymic,duodenal and prostate cancers.

• Major adverse events were neutropenia, leukopenia, anemia, and nausea. G4 neutropenia were resolved by prolongation ofthe washout period (n = 5 ⁄ 5 patients), and reduction of TAS-102 dose (n = 4 ⁄ 5 patients) or administration of GCSF or both(n = 3 ⁄ 5 patients). No febrile neutropenia was observed in any patient in the study.

(no. JapicCTI-111482).

• Postprandial administration was optimal for TAS-102 because trifluridine’s area under the curve was not changed by food,indicating that its clinical efficacy would not be affected. Additionally, postprandial administration was reasonable becausethe maximum concentration of trifluridine decreased in neutrophils, which correlated with previous studies. These resultssuggest that TAS-102 would be an effective treatment for small-cell lung, thymic, and colorectal cancers.

Our experience

• 35 patients treated as compassionate use

• Previous regorafenib in 30 of 35 patients(86%)

Adverse events Any grade Grade ≥3

He

mat

olo

gic Neutropenia 80% 70%

Anemia 70% 14%

Trombocytopenia 10% 0%

Febrile Neutropenia 3% 3%

No

n H

em

ato

logi

c Fatigue 70% 20%

Nausea 25% 0%

Infection (any) 6% 0%

Vomiting 6% 0%

Diarrhea 9% 0%

ADRs in patients treated with TAS-102 at our institutions

Conclusions

• Despite the similar mechanism of action, the toxicity profile ofTAS-102 differs from the known toxicity profiles of 5-FU and itsderivatives.

• Neutropenia is the most common ADR associated to TAS-102

• The incidence of 5-FU-associated AEs such as stomatitis, HFS orDiarrhea is rather low with TAS-102.

• TAS-102, unlike 5-FU, can be administered in patients with a DPDdeficiency.

• TAS-102 seems to be the first cardio-gentle fluoropirimidine.