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1
Translational exposure-efficacy modeling to optimize the dose and schedule of taxanes
combined with the investigational Aurora A kinase inhibitor MLN8237 (alisertib)
Jessica Huck1, Mengkun Zhang1, Jerome Mettetal2, Arijit Chakravarty2, Karthik
Venkatakrishnan3, Xiaofei Zhou3, Rob Kleinfield5, Marc L. Hyer1, Karuppiah Kannan1,
Vaishali Shinde6, Andy Dorner7, Mark Manfredi1, Wen Chyi Shyu2, Jeffrey A. Ecsedy7*
Departments of 1Cancer Pharmacology, 2DMPK, 3Clinical Pharmacology, 4Clinical
Research, 5Drug Development Management, 6Molecular Pathology, 7Translational
Medicine
Takeda Pharmaceuticals International Co.
Cambridge, MA 02139, USA
* For correspondence:
Takeda Pharmaceuticals International Co
35 Landsdowne Street
Cambridge, MA 02139
phone: 617-444-1541
FAX: 617-551-8905
email: [email protected]
Conflict of interest – None
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Financial Support – All research was supported by Takeda Pharmaceuticals
International Co
Running Title: Dose schedule optimization with combined MLN8237 and taxanes
Keywords: Aurora, Alisertib, Paclitaxel, Docetaxel, Combination therapy
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Abstract
Aurora A kinase orchestrates multiple key activities allowing cells to transit successfully
into and through mitosis. MLN8237 (alisertib) is a selective Aurora A inhibitor that is
being evaluated as an anticancer agent in multiple solid tumors and heme-lymphatic
malignancies. The antitumor activity of MLN8237 when combined with docetaxel or
paclitaxel was evaluated in in vivo models of triple negative breast cancer grown in
immunocompromised mice. Additive and synergistic antitumor activity occurred at
multiple doses of MLN8237 and the taxanes. Moreover, significant tumor growth delay
relative to the single agents was achieved after discontinuing treatment; notably,
durable complete responses were observed in some mice. The tumor growth inhibition
data generated with multiple dose levels of MLN8237 and paclitaxel was used to
generate an exposure-efficacy model. Exposures of MLN8237 and paclitaxel achieved
in patients were mapped onto the model after correcting for mouse-to-human variation
in plasma protein binding and maximum tolerated exposures. This allowed rank
ordering of various combination doses of MLN8237 and paclitaxel to predict which pair
would lead to the greatest antitumor activity in clinical studies. The model predicted that
60 and 80 mg/m2 paclitaxel (QW) in patients lead to similar levels of efficacy, consistent
with clinical observations in some cancer indications. The model also supported using
the highest dose of MLN8237 that can be achieved regardless of whether it is combined
with 60 or 80 mg/m2 of paciltaxel. The modeling approaches applied in these studies
can be used to guide dose-schedule optimization for combination therapies using other
therapeutic agents.
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Introduction
Antimitotics are among the most successful classes of chemotherapy used in cancer
care. This class of agents, including the taxanes, vinca alkaloids and epothilones, is
used to treat diverse solid and hematological malignancies as single agents or as part
of combination regimens. Paclitaxel (brand name Taxol®), a taxane, identified in the
1960s and was first approved for use in metastatic ovarian cancer patients in 1992 and
in 1994 in metastatic breast cancer patients. Paclitaxel binds to β-tubulin and prevents
the disintegration of spindle microtubules during mitosis [1], thereby preventing the
normal assembly/disassembly dynamics necessary for spindle microtubules to
appropriately attach chromosomal kinetochores and subsequently segregate the sister
chromatids to the daughter cells. As a result, cells treated with paclitaxel arrest in
mitosis via the activation of the spindle assembly checkpoint and either undergo
apoptosis directly out of mitosis or exit mitosis without completion of cytokinesis, a
process known as mitotic slippage [2, 3]. In the latter case, these cells can die by
apoptosis, arrest by senescence or reenter the cell cycle by endoreduplication.
Docetaxel (brand name Taxotere®) is a more soluble and potent synthetic derivative of
paclitaxel and was approved for use in breast cancer in 1998. At the cellular level,
docetaxel and paclitaxel share a similar mechanism of action.
In addition to agents that directly perturb microtubule dynamics, anti-cancer
therapies are being developed to directly inhibit enzymes that drive normal mitotic
progression [4]. Among these targets are the Aurora kinases, a family of
serine/threonine kinases that comprises three isoforms, Aurora A, Aurora B and Aurora
C. As Aurora C expression is predominantly limited to germ cells, most attempts at
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targeting the Aurora kinases have focused on developing selective inhibitors of Aurora
A, Aurora B or both [5, 6].
Aurora A mediates multiple steps throughout mitosis, including centrosome
maturation and separation, mitotic entry, formation of mitotic spindle poles and spindles,
alignment of chromosomes during metaphase and their subsequent separation during
anaphase [7-11]. The outcomes associated with targeted inhibition of Aurora A kinase
have been studied using multiple experimental modalities including RNA interference,
antibody microinjection, targeted knockout in mice, and with use of small molecule
inhibitors [12, 13]; [14-17]. In mitosis, Aurora A inhibition causes abnormal formation of
the mitotic spindles, resulting in mitotic arrest which is mediated by activation of the
spindle assembly checkpoint. The fate of these arrested cells can vary, and includes
apoptosis directly out of mitosis, exit from mitosis without undergoing cytokinesis
resulting in G1 tetraploidy, or completed cytokinesis albeit with severe chromosome
segregation defects. In the latter two outcomes, the abnormal mitotic divisions can lead
to deleterious aneuploidy resulting in cell death or senescence [13, 18].
MLN8237 (alisertib) is a selective ATP competitive inhibitor of Aurora A kinase
[19] studied in a number of Phase 1 and 2 clinical trials as a single agent and in
combination with other therapeutics, including paclitaxel in recurrent ovarian cancer
(NCT01091428) and with docetaxel in prostate and other advanced solid cancers
(NCT01094288). Multiple preclinical studies demonstrated beneficial antitumor activity
in cultured tumor cells and in efficacy studies in vivo when combining Aurora kinase
inhibitors or Aurora kinase targeted RNA interference in a variety of solid and heme-
lymphatic cancer models with paclitaxel and docetaxel [20-30]. Aurora A inhibition
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using the selective Aurora A kinase inhibitor MLN8054 or RNA interference was shown
to abrogate the spindle assembly checkpoint mediated mitotic delay induced by
paclitaxel [31]. These cells rapidly exited mitosis without completing cytokinesis via
mitotic slippage and enter the G1 portion of the cell cycle with a tetraploid DNA content.
Interestingly, Aurora A overexpression also abrogated the spindle assembly checkpoint
in the presence of microtubule perturbing agents [32, 33].
Here, we demonstrate in preclinical models that the Aurora A kinase inhibitor
MLN8237 significantly enhances the preclinical antitumor activity of docetaxel and
paclitaxel in triple-negative breast cancer models. Triple-negative breast cancers are
characterized as not expressing estrogen receptor, progesterone receptor or HER-2;
therefore these tumors are not susceptible to hormone or HER-2 targeted therapies.
Treatment strategies for triple-negative breast cancer include multiple chemotherapeutic
agents, including taxanes [34]. Though these agents do provide some benefit to
patients, there remains a significant unmet need in this population; therefore alternative
options need to be tested including combination therapy. Here, we build a quantitative
translational exposure-efficacy model using both pre-clinical and clinical data for
MLN8237 and paclitaxel to guide combination dose and schedule strategies for these
agents in patients in order to optimize the potential antitumor activity.
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Materials and Methods
Tumor cell culture and primary human tumors. MDA-MB-231 cells were obtained
from ATCC (Manassas, VA) and cultured in DMEM medium supplemented with heat
inactivated 10% FBS and 1% L-glutamine (Life Technologies Grand Island, NY). MDA-
MB-231 cells were purchased in 2002 and in-house testing showed them to be free of
mycoplasma and murine pathogens. All experiments were conducted with low passage
cells from recently resuscitated frozen stocks. MDA-MB-231 cells (2x10^6) were
injected orthotopically into the mammary fat pad of NCr nude mice. The primary human
tumor xenografts PHTX-02B and PHTX-14B were developed at Takeda
Pharmaceuticals International Co. from tumors that were originally obtained from breast
cancer patients through the Cooperative Human Tissue Network (Brockville, MD) and
were passed by trocar subcutaneously into the flank of NOD SCID mice.
In vivo efficacy studies. MDA-MB-231, PHTX-02B or PHTX-14B tumor-bearing mice
(n=10 animals per group) were dosed orally (PO) with vehicle (10% HPbCD + 3.5%
NaHC03) or MLN8237 (3, 10, or 20 mg/kg) for 21 days using a once daily schedule
(QD) or for 3 days on / 4 days off over 3 consecutive weeks. Docetaxel (5, 10 mg/kg)
and paclitaxel (5, 10, 15, 20, 30 mg/kg) were administered intravenously (IV) on a once
weekly schedule (QW) for a total of three doses. Tumor growth was measured using
vernier calipers. Tumor growth inhibition (TGI) was determined as the average change
in vehicle treated tumors (ΔVehicle) minus the average change in test agents treated
tumors (ΔTreated) divided by ΔVehicle and expressed as a percentage. Tumor growth
delay (TGD) was the difference in the number of days required for each test agent
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treatment group to reach an average tumor volume of 1000 mm3 relative to the vehicle
treated group. Drug combinations were assessed for synergy using observed area
under the curve (AUC) values from the efficacy studies over the 21 days of dosing. The
change in AUC relative to the control was calculated for both single agent treatment
groups as well as the combination group. The interaction between the two compounds
was then assessed by comparing the change in AUC observed in the combination
group to the sum of the changes observed in both single agents. The synergy score for
the combination of MLN8237 (M) and either taxane (T) was defined as 100 *
(mean(AUCMT) – mean(AUCM) – mean(AUCT) + mean(AUCvehicle)) / mean(AUCvehicle). A
two sided t-test was used to determine if the synergy score was significantly different
from zero. If the synergy score was less than zero and the P-value was below 0.05,
then the combination was considered to be synergistic. If the synergy score was above
zero and the P-value was below 0.05, then the combination was considered to be sub-
additive or antagonistic. Otherwise the combination was considered to be additive.
Immunohistochemistry. MDA-MB-231 or PHTX-14B tumor bearing NCr female nude
or NOD SCID mice were dosed with MLN8237 at 10 mg/kg or docetaxel at 5mg/kg or
the two agents combined. Tumor tissue was harvested after multiple days of treatment
and fixed in 10% neutral buffered formalin. Tumor sections were stained for Phospho-
Histone H3 (Ser10) (pHisH3) (Millipore, Billerica, MA ) and MPM2 ( Millipore) as
described previously [35]. The number of cells positive for phosphorylation of Histone
H3 on serine 10 (pHistH3) were counted and averaged in five fields of view and DAPI
nuclear staining was used to estimate the total number of cells in the fields. Apoptotic
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cells in tumor xenograft sections were evaluated by immunohistostaining using Cleaved
Caspase3 (Asp 175) antibody (Cell Signaling Beverley, MA) and were quantified using
Aperio Image analysis software (Leica Microsystems Vista, CA). For histopathological
evaluation, 5 μm sections of formalin fixed, paraffin-embedded tumor samples were
stained with hematoxylin and eosin (HE) using a Leica Autostainer XL (Leica
Biosystems Buffalo Grove, IL). Regions of interest were manually drawn on HE images
using Aperio software to exclude areas of artifacts. Definiens Tissue Studio software
(Definiens Carlsbad, CA) was then used to identify tumor versus non-tumor regions.
Pharmacokinetics. Female Balb/c nude mice bearing the MDA-MB-231 tumor
(approximately 500 mm3) received a single dose of vehicle (10% HPβCD) PO,
MLN8237 PO, docetaxel or paclitaxel IV, or a combination of MLN8237 PO with
docetaxel or paclitaxel IV. Whole blood and tumor samples were collected at specified
time points. Blood samples were collected into tubes containing EDTA and placed on
ice then centrifuged for 5 minutes at 10000 rpm. Plasma was removed into fresh tubes
and stored at -80ºC. Tumors were dissected from the mice, weighed and immediately
frozen on dry ice. Homogenates were prepared in diH2O from frozen tumors using a
FastPrep24 tissue homogenizer. Plasma and tumor homogenates were thawed at
room temperature and the concentration of MLN8237 and paclitaxel or docetaxel in
mouse plasma and tumor samples was determined by HPLC with MS/MS detection.
Pharmacokinetic (PK) analysis was performed in NONMEM (Icon plc, Dublin,
Ireland). Plasma concentrations after a single dose of MLN8237 were fitted to a two-
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compartment model with absorption, and plasma concentrations after a single dose of
paclitaxel were fitted using a two-compartment model with saturable clearance.
Exposure-efficacy modeling. Total MLN8237 exposures (AUC0-21d) on each dosing
regimen (QD and 3 days on / 4 days off) , and total paclitaxel exposures (AUC0-21d) from
QW dosing, were calculated from simulations of plasma concentration based on the
fitted PK models. The simulated plasma concentration time-courses for paclitaxel after
IV dosing and for MLN8237 after PO dosing are shown in Supplementary Figures 1A
and B respectively, and the pharmacokinetic parameters used are shown in
Supplementary Figure1C. Free fractions in female Balb/c Nude mice of 3.4% and 4.2%
for paclitaxel and MLN8237 respectively were determined using rapid equilibrium
dialysis. Kinetic tumor xenograft volume data were converted to TGI using Equation 1.
The TGI values were fit using Pharsight Phoenix (Certara, St Louis, MO) software with a
combination Emax model defined by Equation 2 where AUCMLN and AUCTax represent the
total cycle free exposures of MLN8237 and paclitaxel, respectively. Supplementary
Table 1 contains a list of the best fit parameters. The resulting best fits are shown in
Supplementary Figure 2.
(eq. 1) %)100(%0,21,
0,21, ⋅−−
=dcontroldcontrol
dtreateddtreated
VVVV
TGI .
(eq. 2) γγγ
TaxTax
TaxTax
MLNMLN
MLNMLNTaxMLN ECAUC
AUCEECAUCAUCE
AUCAUCTGI50
max50
max),(%
++
+=
Clinical exposures were estimated for MLN8237 and paclitaxel as follows. The total
cycle AUC of MLN8237 for doses of 10-50 mg BID administered on Days 1-3, 8-10, 15-
17 of 28-day cycles was calculated based on a previously reported geometric mean
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apparent oral clearance of 4.45 L/hr in patients with advanced non-hematologic
malignancies [36]. The corresponding unbound plasma exposures were calculated
based on a free fraction of 2.5% in human plasma using rapid equilibrium dialysis. The
total cycle AUC of paclitaxel for doses of 60-90 mg/m2 administered on Days 1, 8, 15 of
28-day cycles was calculated based on a previously reported clearance of 5.5
mL/min/kg (~ 223 mL/min/m2) [37]. The corresponding unbound plasma exposures
were calculated based on a free fraction of 4.4% in human plasma using rapid
equilibrium dialysis. For comparison with unbound preclinical exposures, a scaling was
applied to the unbound clinical exposures factor based on the unbound exposure ratio
between mouse and human as well as on the maximum tolerated dose between mouse
and humans for MLN8237 (20 mg BID mg/kg QD21 days and 50 mg BID for 7 days on
a 21 day schedule, respectively) and paclitaxel (30 mg/kg QW for 3 weeks and 80
mg/m2 QW for 3 weeks on a 28 day schedule, respectively).
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Results
The antitumor activity of MLN8237 combined with docetaxel was tested in xenograft and
primary human tumor derived triple-negative breast tumor models in
immunocompromised mice. In most mouse strains, the maximum tolerated dose for
MLN8237 is 30 mg/kg dosed daily (QD) or 20 mg/kg dosed twice daily (BID) with an 8
hour break between doses. The maximum tolerated dose for docetaxel was determined
to be 15 mg/kg dosed once weekly (QW) as doses above this led to body weight loss
exceeding 10%. In the MDA-MB-231 xenograft, 3 and 10 mg/kg MLN8237
(QDx21days) combined with 5 and 10 mg/kg docetaxel (QW, days 1, 8 and 15) led to
synergistic antitumor activity (Figure 1A, Table 1). Importantly, MLN8237 at 3 and 10
mg/kg combined with 10 mg/kg docetaxel led to regressions and prolonged tumor
growth delay (difference in days between the control and treated groups to reach 1000
mm3), and in some mice tumors never reformed even after discontinuing treatment. In
comparison, MLN8237 dosed at the maximum tolerated dose in mice bearing the MDA-
MB-231 xenograft did not lead to regressions ([19]). In the primary human tumor
xenograft PHTX-02B, 10 and 20 mg/kg MLN8237 (QDx21days) combined with 5 mg/kg
docetaxel (QW days 1, 8 and 15) led to additive or synergistic antitumor activity (Figure
1B, Table 1). Additive or synergistic antitumor activity also occurred in the PHTX-14B
xenograft with 10 and 20 mg/kg (QDx21days) MLN8237 and 5 and 10 mg/kg (QW days
1, 8 and 15) docetaxel, with sustained tumor regressions occurring only in the
combination regimens (Figure 1C, Table 1). The doses for all treatment regimens
tested were well tolerated as total body weight loss in the mice never exceeded 10%.
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To ensure that the beneficial antitumor activity observed with the MLN8237 and
docetaxel combination was not due to an increase in the exposure of one drug in the
presence of the other, the pharmacokinetic profile of both drugs was tested in mice
bearing the MDA-MB-231 xenograft after a single dose of 10 mg/kg MLN8237, 5 mg/kg
docetaxel or the combination of both (Figure 2A). In plasma and tumor tissue, the
exposures of both MLN8237 and docetaxel were similar whether dosed alone or in
combination with the other agent.
MLN8237 and docetaxel lead to a transient accumulation of cells in mitosis.
Therefore, the effect of a single dose of MLN8237 and docetaxel alone or combined on
the tumor mitotic index was evaluated in mice bearing the MDA-MB-231 xenograft.
Tumor mitotic index was evaluated using two independent markers for mitotic cells,
phosphorylation of Histone H3 on serine 10 (pHistH3) and a mitotic specific antigen
MPM2. In all cases, the mitotic index increased within two hours after dosing; however
there were no notable differences in the mitotic index in the combination relative to the
single agents (Figure 2B).
As no marked change in the mitotic index was observed with combined
MLN8237 and docetaxel relative to the single agents in MDA-MB-231 model, the effect
of the MLN8237 and docetaxel combination on tumor morphology was evaluated after
treating PHTX-14B and MDA-MB-231 tumor bearing mice with 10 mg/kg MLN8237
(QDx10days), 5 mg/kg docetaxel (QW days 1 and 8), or the combination of MLN8237
and docetaxel (Figure 3). In the PHTX-14B tumors, the combination of MLN8237 and
docetaxel led to marked changes in tumor morphology, with increased mitotic and
multinucleated cells and significant fibrosis (Figure 3A). In regions of the tumors where
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viable cells remained, there was a significant increase in non-tumor tissue which
comprised necrotic and fibrotic regions along with stromal infiltrate (Figure 3B). Only a
modest increase in apoptotic cells as determined by cleaved caspase 3 staining was
observed with single agent docetaxel and the combination (Supplementary Figure 3),
potentially due to the transient nature of this marker during the apoptotic cascade. The
morphological effects of the combination were less evident in the MDA-MB-231 model,
however mitotic and multinucleated cells were observed (Figure 3C and 3D).
One of the primary dose limiting toxicities of MLN8237 in cancer patients is
myelosuppression [38, 39]. Therefore, there is risk for overlapping toxicity when
combining MLN8237 with docetaxel or paclitaxel as myelosuppression is a common
dose limiting toxicity for taxanes as well. One path towards reducing the risk of
overlapping toxicity is to decrease the dosing frequency for MLN8237. Therefore, the
antitumor activity of MLN8237 dosed intermittently (3 days on / 4 days off) with
docetaxel once per week (QW) for three consecutive weeks was evaluated. In the
PHTX-02B model, 20 mg/kg MLN8237 dosed 3 days on / 4 days off with 5 mg/kg
docetaxel (QW days 1,8 and 21) resulted in significant tumor growth inhibition and
tumor growth delay relative to the single agents (Figure 4A, Table 1). MLN8237 dosed
3 days on / 4 days off with docetaxel dosed weekly resulted in synergistic antitumor
activity in the PHTX-14B model as well (Figure 4B, Table 1). In fact, the extent of
antitumor activity (TGI and TGD) achieved with the combination in both models with the
3 days on / 4 days off schedule equaled that observed when MLN8237 was dosed
consecutively for 21 days at an identical total daily dose. These data support dosing
MLN8237 on an intermittent schedule as a potential means to minimize overlapping
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dose-limiting toxicities while maintaining antitumor activity when combined with weekly
taxanes.
The in vivo antitumor activity of MLN8237 was also tested in combination with
paclitaxel in the MDA-MB-231 and PHTX-14B xenografts (Figure 5, Table 2). The
maximum tolerated dose for paclitaxel was determined to be 30 mg/kg dosed once
weekly (QW) as doses above this led to body weight loss exceeding 10%. In the MDA-
MB-231 xenograft, 3, 10 and 20 mg/kg MLN8237 (QDx21days) combined with 5, 10, 15,
20 or 30 mg/kg paclitaxel (QW days 1, 8, and 15) led to additive or synergistic antitumor
activity (Figure 5A, Table 2). With 10 and 20 mg/kg MLN8237, paclitaxel at 20 and 30
mg/kg led to substantial tumor growth delay (Table 2). In the primary human tumor
xenograft PHTX-14B, 20 mg/kg MLN8237 (QD) combined with 10 and 20 mg/kg
paclitaxel (QW) led to synergistic antitumor activity (Figure 5B, Table 2) with tumor
growth delay extending beyond the observation period. The antitumor activity of
MLN8237 dosed intermittently (3 days on / 4 days off) with paclitaxel once per week
(QW) for three consecutive weeks was also evaluated. In the MDA-MB-231 model, 20
mg/kg MLN8237 dosed 3 days on / 4 days off with 20 mg/kg paclitaxel (QW days 1,8
and 21) resulted in additive tumor growth inhibition relative to the single agents
(Supplementary Figure 4). Total body weight loss in mice for all MLN8237 and
paclitaxel treatment regimens never exceeded 10%. In addition, no pharmacokinetic
drug-drug interaction between MLN8237 and paclitaxel was observed in mice as the
pharmacokinetic profiles for each agent in plasma and MDA-MD-231 tumor tissue were
similar whether dosed alone or in combination with the other agent (Supplementary
Figure 5).
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The durable antitumor activity of MLN8237 combined with both docetaxel and
paclitaxel in preclinical tumor models presented provided part of the rationale for
evaluating the safety and antitumor activity of MLN8237 combined with paclitaxel in
recurrent ovarian cancer patients (NCT01091428). In this clinical study, MLN8237 was
dosed BID 3 days on / 4 days off concomitantly with paclitaxel dosed weekly (QWx3) at
60 or 80 mg/m2 on a 28-day schedule [40]. In order to guide dose-schedule selection
for combined MLN8237 and paclitaxel in cancer patients, an exposure-efficacy model
based on non-clinical and clinical data was developed to predict which MLN8237 /
paclitaxel combinations results in the greatest antitumor efficacy. An exposure-efficacy
surface plot (Figure 6A) and isobologram (Figure 6B) relating MLN8237 and paclitaxel
exposures to tumor growth inhibition was generated from in vivo efficacy studies in
tumor-bearing mice (Table 2). The free-fraction corrected clinical exposures of
MLN8237 dosed BID based on previously published pharmacokinetic data[36, 39] and
the clinical exposures of paclitaxel at 60 or 80 mg/m2 doses of paclitaxel determined
from its human plasma clearance [37, 41] were mapped onto the isobologram by
correcting for mice-human variation in plasma protein binding and maximum tolerated
exposures for both agents. A combination Emax exposure-efficacy model provided a
reasonable fit to the data, as is shown in the diagnostic plots (Supplementary Figure 2).
This translational approach demonstrated allowed placing the clinically achieved
exposures of the combination in the context of the preclinically observed antitumor
efficacy. Placed in this context, the model predicted that 80 and 60 mg/m2 paclitaxel
lead to similar levels of efficacy (Figure 6B and C), consistent with clinical observations
in some cancer indications [42, 43]. In contrast, placing the MLN8237 exposures in the
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context of the preclinical antitumor efficacy suggests that increasing the dose of
MLN8237 from 10 up to 50 mg BID would result in increasing antitumor activity (Figure
6B and C). This approach allows for rank ordering various combination doses and
schedules of MLN8237 and paclitaxel to predict which pair leads to the greatest
antitumor activity. For example, overlapping toxicities could prevent escalation of
MLN8237 to a biologically active exposure range when combined with 80 mg/m2
paclitaxel. If reducing the dose of paclitaxel to 60 mg/m2 can mitigate overlapping
toxicities allowing for higher MLN8237 doses, the translational approach demonstrated
here suggests that this would also result in increased antitumor activity relative to 80
mg/m2 single agent paclitaxel.
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Discussion
Antimitotic therapies are a mainstay for cancer care, as they are used broadly in
both solid and heme-lymphatic cancers. Traditionally, these therapies have comprised
agents that directly target microtubules, and include the taxanes, vinca alkaloids and
epothilones. Recently, encouraging activity has been observed with microtubule-
perturbing agents such as the microtubule destabilizer mono-methyl aurastatin E
conjugated to antibodies, including brentuximab vedotin and trastuzumab-DM1 for
treating CD30+ lymphomas and Her2+ breast cancer respectively [44, 45]. Despite the
success of antimitotic therapies across many indications, strategies to improve
response rates and extend responses in patients are needed. Here, we demonstrated
improved antitumor activity and extended duration of response in multiple triple negative
breast cancer models by combining two classes of antimitotic agents, taxanes and the
Aurora A kinase inhibitor MLN8237.
Mice bearing three xenograft models of triple negative breast cancer including two
primary models were treated with various doses of MLN8237 combined with docetaxel
or paclitaxel. In each tumor model, the combination led to greater tumor growth
inhibition relative to the single agents, additive or synergistic antitumor activity while
dosing, and prolonged tumor growth delay after discontinuing treatment. Notably, in
several cases the combination of MLN8237 and either taxane led to tumor regressions
and in some mice the tumors never reformed after discontinuing treatment; outcomes
that did not occur with the single agents when dosed at the individual maximum
tolerated dose.
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In MDA-MB-231 tumor xenografts treated with combined MLN8237 and docetaxel,
there was no notable difference in the mitotic index, necrotic and fibrotic content, or
stromal infiltrate compared to tumors treated with the single agents after 10 days of
dosing. It is possible that the timing of this analysis in this tumor model was not optimal
to capture the events underlying the antitumor activity observed after 21 days of dosing.
However, the impact of this combination on tumor morphology was more evident in the
PHTX-14B tumor xenograft as a histopathological assessment revealed distinct tissue
morphology changes in combination treated tumors relative to the single agent treated
tumors, including increased non-tumor tissue (necrotic cells, fibrosis, stromal infiltrate)
and multinucleated tumor cells. The multinucleated phenotype is consistent with
previous observations in cultured tumor cells demonstrating that concurrent Aurora A
kinase inhibition using the selective small molecule inhibitor MLN8054 or siRNA with
microtubule perturbing agents including taxanes caused cells to exit mitosis via mitotic
slippage [31]. Cells that exit mitosis by mitotic slippage enter the G1 stage of the cell
cycle with a tetraploid DNA content often accompanied by multiple nuclei due to hyper-
karyokinesis that can occur when the nuclear membrane reforms [2] [4]. Depending on
several underlying genetic factors, these cells can reenter the cell cycle and undergo
another round of DNA replication through a process known as endoreduplication where
they subsequently are characterized as polyploid (>4N). Therefore, the multinucleated
phenotype observed in the tumor tissue with combined MLN8237 and docetaxel
suggests that the mechanism elucidated in cell culture with Aurora A inhibition
combined with taxanes occurs in in vivo tumor models as well.
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MLN8237 has been evaluated in multiple PI and PII clinical studies [36] [39, 46, 47].
In the first-in-human P1 study, a partial response was achieved in one patient with
platinum and radiation refractory ovarian cancer that lasted for greater than 1 year [38].
Single agent MLN8237 was subsequently investigated in a phase II study in patients
with platinum-resistant or platinum-refractory ovarian, primary peritoneal and fallopian
tube cancers [48]. In this study, objective responses occurred in 10% of patients (n=3
out of 31) as determined by Response Evaluation Criteria in Solid Tumors (RECIST)
and/or reduction in plasma CA-125, warranting further MLN8237 studies in this
indication in combination with other therapeutics including with taxanes.
MLN8237 was tested in combination with weekly paclitaxel in patients with
recurrent ovarian cancer (NCT01091428) [40]. Given that myelosuppression is a
common adverse event for both MLN8237 and paclitaxel, weekly paclitaxel (QWX3 28
day cycle) was selected for this study as it is known to have a decreased incidence of
myelosuppression relative to paclitaxel dosed once every 3 weeks [49, 50]. For
MLN8237, an intermittent schedule of 3 days on (BID) / 4 days off was selected for
combining with weekly paclitaxel, rather than using the single agent MLN8237
recommended schedule of days 1 through 7 on a 21 day cycle [38, 39]. This
intermittent schedule allows for concurrent administration of MLN8237 with weekly
paclitaxel which may be necessary for amplifying the mitotic defects caused by this
combination. Importantly, this intermittent MLN8237 schedule may also further reduce
the risk for overlapping toxicities such as myelosuppression. Previous studies modeling
hematological toxicity by assessing the PK-absolute neutrophil count (ANC) relationship
in rats using methods similar to those described by Friberg and colleagues [51]
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predicted MLN8237 dosed on an intermittent schedule of 3 days on (BID) / 4 days off
concomitantly with the weekly taxanes will decrease the incidence of dose limiting
neutropenia compared with a 7 day continuous schedule [52]. Moreover, the
approximate 23 hour mean steady state half life of the drug in patients allows for near
complete MLN8237 clearance during the 4 day break which should allow for reversion
of myelosuppressive effects caused by MLN8237 [38]. In our in vivo efficacy
experiments we showed that MLN8237 dosed 3 days on / 4 days off was synergistic
when combined with weekly docetaxel. Of note, the extent of the antitumor activity for
docetaxel combined with MLN8237 dosed 3 days on / 4 days off was nearly identical to
that of MLN8237 dosed for 21 consecutive days. Importantly the intermittent dosing
schedule enabled a significant decrease in the total dose of MLN8237 by 57%. In the
MDA-MB-231 model, continuous dosing of MLN8237 led to slightly greater antitumor
activity relative to dosing 3 days on / 4 days off when combined with paclitaxel,
however, both MLN8237 schedules led to additive antitumor activity.
We developed an exposure-efficacy model to relate MLN8237 and paclitaxel
exposures to antitumor activity using tumor growth inhibition from the efficacy studies
performed with the MDA-MB-231 xenograft. This model was translationally applied in
context of clinical exposures of paclitaxel and MLN8237 after inter-species corrections
for plasma protein binding and maximum tolerated exposures of the two agents. An
isobolographic representation of the response surface was used to rank order pairs of
doses of the two agents in the combination setting. This translational PK-efficacy
analysis predicted that the combination of MLN8237 and paclitaxel at the doses
explored in the clinic will have greater antitumor activity than the single agent standard
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dose for paclitaxel (80 mg/m2) and MLN8237 (50 mg BID) (Figure 6C). In addition, the
modeling predicted that 80 and 60 mg/m2 paclitaxel lead to similar levels of efficacy
alone or in combination with MLN8237. Several observations have been reported that
paclitaxel as a single agent or in combination with other therapeutics dosed weekly at
60 mg/m2 provides similar efficacy to paclitaxel at 80 mg/m2, however 60 mg/m2 is
better tolerated [42, 43] . The model also predicted that higher doses of MLN8237 with
either dose of paclitaxel will lead to increased antitumor activity. Therefore, in patients,
if higher doses of MLN8237 can be achieved with 60 mg/m2 rather than 80 mg/m2 of
paclitaxel, the model predicts increased antitumor activity. In addition, an exposure
related pharmacodynamic effect in tumors was demonstrated during phase 1 testing of
MLN8237 [39], suggesting that the doses of MLN8237 between 30 and 50 mg BID are
likely to result in biologically active exposures in regard to Aurora A kinase inhibition in
tumors. Therefore, both the exposure-efficacy model and the phase 1
pharmacodynamic results support using higher doses of MLN8237 when combined with
paclitaxel.
Viewed from a broader perspective, more generalized applications of the
quantitative model-based translational pharmacology approach applied in this analysis
of the MLN8237-paclitaxel combination are readily apparent. As dose escalation studies
in patient populations with advanced cancers can be resource and time-consuming and
not all dose pairs can be clinically evaluated, it is envisioned that systematic analysis of
the exposure-efficacy surface for antitumor activity in preclinical xenograft models may
represent a key enabler for clinical development of oncology drug combinations. These
results, when coupled with clinical pharmacokinetic, pharmacodynamic and safety data
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analyses, offer potential to objectively guide prioritization and optimization of dose-
finding in combination Phase 1 trials to support qualification of the therapeutic window
for optimal benefit-risk balance in anticancer drug development.
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Table 1. Antitumor activity summary of MLN8237 combined with docetaxel
Model
MLN8237 dose (QD or 3on/4off)
Docetaxel dose(Q7Dx3)
TGIc (%)
TGD (days)d
Outcome (AUC)e
MDA-MB-231 a 3mg/kg 5mg/kg 54.2 7 Synergistic
10mg/kg 5mg/kg 91.8 >48 Synergistic
10mg/kg 5mg/kg 67.3 11 Synergistic
3mg/kg 10mg/kg 112.7 46 Synergistic
10mg/kg 10mg/kg 117.9 >106 Synergistic
10mg/kg 10mg/kg 106.1 >41 Synergistic
PHTX-02Bb 10mg/kg 5mg/kg 95.2 35 Synergistic
20mg/kg 5mg/kg 101.7 51 Synergistic
20mg/kg 5mg/kg 99.3 49 Additive
20mg/kg 3on/4off 5mg/kg 103.9 >51 Synergistic
PHTX-14Bb 10mg/kg 5mg/kg 123.4 >45 Synergistic
20mg/kg 5mg/kg 125.4 >45 Synergistic
10mg/kg 10mg/kg 128 >45 Synergistic
20mg/kg 10mg/kg 134 >45 Synergistic
3mg/kg 3on/4off 5mg/kg 85.6 38 Additive
20mg/kg 3on/4off 5mg/kg 123 >60 Synergistic
3mg/kg 3on/4off 10mg/kg 121.5 >60 Additive
20mg/kg 3on/4off 10mg/kg 140.1 >76 Synergistic aOrthotopic MDA-MB-231 xenografts were grown in the fat pad of nude mice and treated with MLN8237 administered orally for 21 days with docetaxel dosed IV once per week bPrimary breast cancer models were grown SC in SCID (PHTX-14B) or NOD (PHTX-02B) mice and treated with MLN8237 administered orally for 21 days with docetaxel dosed IV once per week cTumor growth inhibition (TGI) =(Δ treated / Δ control) x 100 / Δ control, was calculated on the last day of treatment dTumor Growth Delay (TGD) The difference in days between the control and the treated groups to reach 1000mm3. > denotes that the treatment group was terminated prior to reaching 1000mm3 eSynergy analysis based on the area under the curve (AUC) values days 0 through 20
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Table 2. Antitumor activity summary of MLN8237 combined with paclitaxel
Model MLN8237 dose
(QD) Paclitaxel dose
(Q7Dx3) TGIc (%)
TGD (days)d
Outcome (AUC)e
MDA-MB-231a 20mg/kg 30mg/kg 101.4 35 Synergistic
20mg/kg 20mg/kg 94.3 26 Synergistic
20mg/kg 20mg/kg 96.3 24 Synergistic
20mg/kg 15mg/kg 85.7 16 Additive
20mg/kg 10mg/kg 45.87 4 Additive
20mg/kg 5mg/kg 43.6 4 Additive
10mg/kg 30mg/kg 102.4 31 Synergistic
10mg/kg 20mg/kg 81.9 13 Additive
10mg/kg 15mg/kg 85.6 14 Additive
10mg/kg 10mg/kg 42.3 4 Additive
3mg/kg 20mg/kg 69.2 10 Additive
3mg/kg 20mg/kg 60.5 7 Additive
3mg/kg 10mg/kg 21.7 2 Additive
3mg/kg 5mg/kg 20.8 2 Additive
PHTX-14Bb 20mg/kg 20mg/kg 103 >14 Synergistic
20mg/kg 10mg/kg 84 >14 Synergistic
3mg/kg 20mg/kg 72 >14 No data aOrthotopic MDA-MB-231 xenografts were grown in the fat pad of nude mice and treated with MLN8237 administered orally for 21 days with paclitaxel dosed IV once per week bPrimary breast cancer models were grown in SCID mice and treated with MLN8237 administered orally for 21 days with paclitaxel dosed IV once per week cTumor growth inhibition (TGI) =(Δ treated / Δ control) x 100 / Δ control, was calculated on the last day of treatment dTumor Growth Delay (TGD) The difference in days between the control and the treated groups to reach 1000mm3. > denotes that the treatment group was terminated prior to reaching 1000mm3 * Treatment group was terminated prior to reaching 1000mm3 eSynergy analysis based on the area under the curve (AUC) values days 0 through 20
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32
Figure legends
Figure 1. MLN8237 combined with docetaxel results in antitumor activity in three
models of triple negative breast cancer, including the cell line xenograft MDA-MB-231
(A), the primary human breast tumor xenograft PHTX-02B (B), and the primary human
breast tumor xenograft PHTX-14B (C). Mice were treated for 21 days with MLN8237
(PO, QD), docetaxel (IV, QWx3), or the combination of both at the indicated doses.
Tumors were measured twice weekly with vernier calipers and error bars represent
standard error of the mean. The dotted line box indicates the 21 day treatment period.
Figure 2. MLN8237 and docetaxel exposures are similar when dosed alone or in
combination and result in an increased mitotic index. A single dose of MLN8237 (10
mg/kg), docetaxel (5 mg/kg), or the combination of both was administered to mice
bearing MDA-MB-231 xenografts. Blood and tumor samples were taken at multiple
times out to 24hours. (A) MLN8237 and docetaxel concentrations are shown in both the
plasma and the MDA-MB-231 tumor xenograft. (B) MDA-MB-231 tumor sections
(n=3/group) were stained with fluorescently labeled antibodies directed against
phosphorylated Histone H3 on serine 10 (pHistH3) or MPM2 and the staining was
quantified as described in the Materials and Methods. Error bars represent standard
deviation.
Figure 3. Hematoxylin and eosin (H&E) staining of tumor xenografts results in
morphological changes following single agent or combination treatment with MLN8237
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33
and docetaxel. Mice bearing PHTX-14B (A and B) and MDA-MB-231 (C and D)
xenografts were treated with vehicle, MLN8237 (10mg/kg PO, QD) docetaxel (5mg/kg
IV Q7D) or the combination of both for 10 days. On Day 10 tissues were harvested and
fixed in 10% neutral buffered formalin. Tumor sections were stained by H&E and
imaged. Tumor and non-tumor areas were quantified in regions of the tumors that
maintained viable cells using Definiens Tissue Studio software.
Figure 4. MLN8237 administered on an intermittent 3 days on / 4 days off schedule
combined with docetaxel results in significant antitumor activity in two primary breast
tumor models, PHTX-02B (A) and PHTX-14B (B). Tumor bearing mice were treated
with MLN8237 administered once daily for 3 days for three weeks (3on/4off), docetaxel
administered once weekly for 3 weeks, or the combination of both. Tumors were
measured twice weekly with vernier calipers and error bars represent standard error of
the mean. The dotted line box indicates the 21 day treatment period.
Figure 5. MLN8237 combined with paclitaxel results in significant antitumor activity in
the MDA-MB-231 (A) and PHTX-14B (B) tumor models. Tumor bearing mice were
treated for 21 days with MLN8237 (PO, QD), paclitaxel (IV, Q7D), or the combination of
both. Tumors were measured twice weekly with vernier calipers and error bars
represent standard error of the mean. The dotted line box indicates the 21 day
treatment period.
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34
Figure 6. A surface response plot relating MLN8237 and paclitaxel exposures to tumor
growth inhibition (%TGI) generated from multiple in vivo efficacy studies in mice bearing
the MDA-MB-231 xenograft (blue dots) (A). An isobologram derived from the surface
response plot (B). Clinically achieved exposures of MLN8237 (10 or 40 mg BID) and
paclitaxel (60 or 80 mg/m2) from the NCT01091428 study represented by the red stars
were mapped onto the isobologram by correcting for mouse-to-human variation in
plasma protein binding and maximum tolerated exposures for both agents (AUCu/CF
(Correction Factor)). Predicted tumor growth inhibition derived from the exposure-
efficacy surface response plot with increasing doses of MLN8237 administered BID with
or without paclitaxel (C).
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Figure 1ol
ume
(mm
3 )
1500
2000
A MDA-MB-231
Treatment Period Treatment Period
1000
1500
lum
e (m
m^3
)
Ave
rage
Tum
or V
o
0
500
1000
0 10 20 30 40 50 60Days
Vehicle MLN8237 3mg/kg Vehicle MLN8237 10mg/kg
0
500
0 10 20 30 40 50 60
Days
Ave
rage
Tum
or V
ol
B
MLN8237 3mg/kg Docetaxel 5mg/kg
MLN8237 3mg/kg Docetaxel 10mg/kg
Docetaxel 5mg/kg Docetaxel10mg/kg
Vehicle
Docetaxel 5mg/kg Docetaxel10mg/kg
MLN8237 10mg/kg Docetaxel 5mg/kg
MLN8237 10mg/kg Docetaxel 10mg/kg
MLN8237 10mg/kg
PHTX-02B
500
1000
1500
2000
2500
e Tu
mor
Vol
ume
(mm
3 )
e Tu
mor
Vol
ume
(mm
3 )
500
1000
1500
2000
2500Treatment PeriodTreatment Period
0
500
0 10 20 30 40 50 60Days
Ave
rage
Ave
rag
0
500
0 20 40 60 80Days
Vehicle MLN8237 10mg/kg QD
MLN8237 10mg/kg QD/Docetaxel 5mg/kg
Docetaxel 5mg/kg Q7D
Vehicle
Docetaxel 5mg/kg Q7D
MLN8237 20mg/kg QD
MLN8237 20mg/kg QD/Docetaxel 5mg/kg
C
2000
2500
m^3
) 2000
2500
mm
^3)
PHTX-14B
Treatment Period Treatment Period
0
500
1000
1500
0 20 40 60 80 100
Ave
rage
Tum
or V
olum
e (m
m
0
500
1000
1500
0 20 40 60 80 100
Ave
rage
Tum
or V
olum
e (m
0 20 40 60 80 100
Days Days
Vehicle MLN8237 20mg/kg QD
MLN8237 10mg/kg QDDocetaxel 5mg/kg
MLN8237 20mg/kg QD Docetaxel 5mg/kg
MLN8237 10mg/kg QD Docetaxel 5mg/kg
Vehicle MLN8237 20mg/kg QD
MLN8237 10mg/kg QD Docetaxel 10mg/kg
MLN8237 20mg/kg QD Docetaxel 10mg/kg
MLN8237 10mg/kg QD Docetaxel 10mg/kg
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A
1000
10000
1000
10000
Figure 2
10
100
MLN
8237
(ng/
mL)
MLN8237 Plasma
MLN8237/Docetaxel Plasma
MLN8237 Tumor
MLN8237/Docetaxel Tumor
10
100
Doc
etax
el (n
g/m
L)
Docetaxel Plasma
MLN8237/Docetaxel PlasmaDocetaxel Tumor
MLN8237/Doceta el T mor10 5 10 15 20 25
Time (hr)
10 5 10 15 20 25
Time (hr)
MLN8237/Docetaxel Tumor
7.00
8.00 % MPM2 Positive% pHistH3 Positive
B
3.00
4.00
5.00
6.00
% P
ositi
ve C
ells
0.00
1.00
2.00
0 2 4 6 8 16 24 0 2 4 6 8 16 24 0 2 4 6 8 16 24Hours
%
MLN8237 10 mg/kg Docetaxel 5 mg/kg MLN8237 10 mg/kg Docetaxel 5 mg/kg
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PHTX-14B Day 10
Figure 3
A
Vehicle MLN8237
B
90
100
PHTX-14B Day 10
Tumor
CombinationDocetaxel
20
30
40
50
60
70
80
% A
rea
Non-tumor
0
10
Vehicle MLN8237 Docetaxel Combination
Vehicle MLN8237
MDA-MB-231 Day 10C
DD
60
70
80
90
100
a
MDA-MB-231 Day 10
TumorNon-tumor
CombinationDocetaxel
0
10
20
30
40
50
60
Vehicle MLN8237 Docetaxel Combination
% A
rea
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APHTX-02B
Figure 4
0
500
1000
1500
2000
2500
Ave
rage
Tum
or V
olum
e (m
m3 )
Treatment Period
00 20 40 60 80
Days
A
Vehicle MLN8237 20mg/kgMLN8237 20mg/kg Docetaxel 5mg/kg
Docetaxel 5mg/kg
B
Treatment Period20003)
BPHTX-14B
2000
3)
Treatment Period
0
500
1000
1500
0 20 40 60 80 100
Ave
rage
Tum
or V
olum
e (m
m^3
0
500
1000
1500
Ave
rage
Tum
or V
olum
e (m
m^3
0 20 40 60 80 100Day
Vehicle MLN8237 3mg/kg
Docetaxel 10mg/kgDocetaxel 5mg/kg MLN8237 3mg/kg +Taxotere 10mg/kg
MLN8237 3mg/kg +Taxotere 5mg/kg
00 20 40 60 80 100 120
Day
Vehicle MLN8237 20mg/kg
Docetaxel 10mg/kgDocetaxel 5mg/kg
MLN8237 20mg/kg +Taxotere 10mg/kgMLN8237 20mg/kg +Taxotere 5mg/kg
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2500
3000
m^3
)
Treatment Period
A MDA-MB-231Figure 5
0
500
1000
1500
2000
Ave
rage
Tum
or V
olum
e (m
m
00 10 20 30 40
Days
Vehicle MLN8237 20mg/kg
MLN8237 10mg/kg Paclitaxel 20mg/kg
MLN8237 20mg/kg/Paclitaxel 20mg/kg
MLN8237 10mg/kg/Paclitaxel 20mg/kg
1400Treatment Period
B PHTX-14B
400
600
800
1000
1200
vera
ge T
umor
Vol
ume
(mm
^3)
0
200
0 10 20 30 40 50
Days
Av
Vehicle MLN8237 20mg/kg
Paclitaxel 20mg/kg Paclitaxel 10mg/kg
MLN8237 20mg/kg Paclitaxel 20mg/kg
MLN8237 20mg/kg Paclitaxel 10mg/kgPaclitaxel 20mg/kg Paclitaxel 10mg/kg
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Figure 6
A
% T
GI
MLN8237 AUCu (nM.h)Paclitaxel AUCu (ng/ml.h)
500080mg/m2 Paclitaxel
B
Pac
litax
el A
UC
(ng.
hr/m
L)
55 60 65 70 75 80
85 90
2500
3000
3500
4000
450080mg/m2 Paclitaxel
+ 10mg BID 3-3-3 MLN8237
60mg/m2 Paclitaxel 60mg/m2 Paclitaxel+ 40mg BID 3-3-3 MLN8237
Tota
l Cyc
le U
nbou
nd
5 10 15 20 25 30 35 40
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 50
500
1000
1500
2000
Total Cycle Unbound MLN8237 AUC (nM.hr) x 104
70
80
90
100
Inhi
btio
n
C
10
20
30
40
50
60
70
redi
cted
% T
umor
Gro
wth
0 mg/m2 paclitaxel
60 or 80 mg/m2 paclitaxel
00 10 20 30 40 50
Pr
MLN8237 Dose (mg BID)
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Published OnlineFirst June 30, 2014.Mol Cancer Ther Jessica Huck, Mengkun Zhang, Jerome Mettetal, et al. Aurora A kinase inhibitor MLN8237 (alisertib)and schedule of taxanes combined with the investigational Translational exposure-efficacy modeling to optimize the dose
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