Clinical Trial Results Phase I Study of Lenalidomide and Sorafenib in Patients With Advanced Hepatocellular Carcinoma SAFI SHAHDA, a PATRICK J. LOEHRER, a ROMNEE S. CLARK, b A. JOHN SPITTLER, a SANDRA K. ALTHOUSE, a E. GABRIELLA CHIOREAN c a Indiana University School of Medicine, Indianapolis, Indiana, USA; b Endocyte, Inc., West Lafayette, Indiana, USA; c University of Washington School of Medicine, Seattle, Washington, USA TRIAL INFORMATION x ClinicalTrials.gov Identifier: NCT01348503 x Sponsor: Celgene x Principal Investigator: E. Gabriella Chiorean x IRB Approved: Yes LESSONS LEARNED x Combination therapies in patients with hepatocellular carcinoma can be associated with overlapping toxicity and are therefore poorly tolerated. x Using sorafenib at the maximum tolerated dose can lead to a higher incidence of toxicities. Consequently, combination studies might evaluate sorafenib at alternative schedules or doses to improve tolerance, recognizing this could affect sorafenib efficacy. x Although this combination was poorly tolerated, it does not exclude further evaluation of new-generation immunomodulator drugs or immune checkpoint inhibitors in the hope of optimizing tolerance and safety. ABSTRACT Background. Sorafenib is the standard treatment for advanced hepatocellular carcinoma (HCC), and to date, no combination therapy has demonstrated superior survival compared with sorafenib alone. The immunosuppressive microenvironment in HCC is a negative predictor for survival. Lenalidomide is an immunomodulator and antiangiogenic agent, with limited single-agent efficacy in HCC. Based on these data, we designed a phase I study of sorafenib plus lenalidomide to determine the safety and preliminary antitumor activity of this combination. Methods. This was an open-label, phase I study with a 313 dose escalation/de-escalation design. The starting dose of sorafenib was 400 mg p.o. b.i.d. and of lenalidomide was 15 mg p.o. daily with a planned dose escalation by 5 mg per cohort up to 25 mg daily. Dose de-escalation was planned to a sorafenib dose of 400 mg p.o. daily combined with two doses of lenalidomide: 10 mg p.o. daily for a 28-day cycle (cohort 1) and 10 mg p.o. daily for a 21- or 28-day cycle (cohort 2). Patients with cirrhosis, a Child-Pugh score of A-B7, and no previous systemic therapy were eligible. Results. Five patients were enrolled. Their median age was 56 years (range 39–61), and the ECOG status was 0–2. Four patients were treated at dose level (DL) 1. Because of the poor tolerance to the combination associated with grade 2 toxicities, one more patient was treated at DL 21. No dose-limiting toxicity was observed as specified per protocol. The most common toxicities were nausea, anorexia, pruritus, elevated liver enzymes, and elevated bilirubin. Three patients experienced one or more of the following grade 3 toxicities: fatigue (DL 1), increased bilirubin (DL 1), skin desquamation (DL 21), and elevated transaminase levels (DL 1).The median duration of therapy was 1 cycle (range 1–3). All patients discontinued the study, 4 because of progressive disease and 1 by patient preference. The best confirmed response was progressive disease. The median progression-free survival was 1.0 month (95% confidence interval 0.9–2.8), and the median overall survival was 5.9 months (95% confidence interval 3.68–23.4). Conclusion. In our small study, the combination of lenalidomide and sorafenib was poorly tolerated and showed no clinical activity. Although the study was closed early because of toxic- ity concerns, future studies assessing combinations of sorafenib with new-generation immunomodulator drugs or other immunomodulatory agents, should consider lower starting doses of sorafenib to avoid excessive toxicity. The Oncologist 2016;21:664–665d DISCUSSION Patients with HCC have limited therapeutic options. Sorafenib, a multi-tyrosine kinase inhibitor, is the only Food and Drug Administration (FDA)-approved systemic therapy for this disease, with marginal improvement in median overall Correspondence: Safi Shahda, M.D., Indiana University School of Medicine, 535 Barnhill Drive, Route 130C, Indianapolis, Indiana 46202, USA.Telephone: 317- 274-0320; E-Mail: shahdas@iu.edu Received February 17, 2016; accepted for publication March 21, 2016; published Online First on June 2, 2016. ©AlphaMed Press; the data published online to support this summary is the property of the authors. http://dx.doi.org/10.1634/theoncologist.2016-0071 The Oncologist 2016;21:664–665d www.TheOncologist.com ©AlphaMed Press 2016 Downloaded from https://academic.oup.com/oncolo/article/21/6/664/6401447 by guest on 16 July 2022