Small Molecules in Oncology

Volume 211

Recent Results in Cancer Research

Series Editors

Alwin Krämer

German Cancer Research Center (DKFZ) and University of Heidelberg, Heidelberg, Germany

Jiade J. Lu

Shanghai Proton and Heavy Ion Center, Shanghai, China

More information about this series at http://​www.​springer.​com/​series/​392

Editor

Uwe M. Martens

Small Molecules in Oncology3rd ed. 2018

Editor

Uwe M. Martens

MOLIT Institute, Cancer Center Heilbronn-Franken, SLK-Clinics, Heilbronn, Baden-Württemberg, Germany

ISSN 0080-0015e-ISSN 2197-6767

Recent Results in Cancer Research

ISBN 978-3-319-91441-1e-ISBN 978-3-319-91442-8

https://doi.org/10.1007/978-3-319-91442-8

Library of Congress Control Number: 2018941220

Originally published in one volume in previous edition

© Springer International Publishing AG, part of Springer Nature 2018

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Preface

The past two decades have resulted in major breakthroughs in the treatment of cancer. Even though conventional chemotherapy currently remains the backbone of most treatment regimens, the paradigm of cancer therapy is shifting unambiguously toward more selective, mechanism-based strategies.

With the tremendous advances in our recent understanding of aberrant signaling pathways in various types of cancer—including leukemia, breast and lung cancer, and melanoma—plenty of crucial regulators of malignant behavior in cancer cells have emerged as promising candidates for molecular target-based cancer therapies.

Specific alterations in key signaling molecules driving the progression of individual cancers can now precisely be targeted by small low-molecular-weight compounds. This new class of rationally designed anticancer agents is able to induce striking regressions in molecularly defined subsets of patients.

One of the early pioneers has been imatinib mesylate (Glivec ® ) that showed remarkable efficacy for the treatment of patients with Philadelphia chromosome-positive CML, changing the course of this formerly deadly disease profoundly. A recent major breakthrough represents the discovery of synthetic lethality of PARP inhibitors in cancers defective in homologous recombination repair (HR), e.g., those associated with BRCA1 and BRCA2 mutations.

With the third edition of Small Molecules in Oncology , we aim to give you a comprehensive survey of both, already established drugs as well as promising new substances. All chapters have been contributed by renowned scientists and clinicians, offering first-hand insight into the exciting and rapidly evolving field of targeted cancer therapies. Due to the tremendous amount of available agents, the book has now been divided into two volumes, while Small Molecules in Oncology covers the treatment options in solid tumors and Small Molecules in Hematology focuses mainly on molecularly targeted drugs in hematologic malignancies.

Uwe M. Martens

Heilbronn, Germany

Contents

Erlotinib 1

Martin Steins, Michael Thomas and Michael Geißler

Lapatinib 19

Minna Voigtlaender, Tanja Schneider-Merck and Martin Trepel

Regorafenib 45

Thomas J. Ettrich and Thomas Seufferlein

Crizotinib 57

David F. Heigener and Martin Reck

Cabozantinib:​ Multi-kinase Inhibitor of MET, AXL, RET, and VEGFR2 67

Carsten Grüllich

Vemurafenib 77

Claus Garbe and Thomas K. Eigentler

Trametinib (GSK1120212) 91

Robert Zeiser, Hana Andrlová and Frank Meiss

Everolimus 101

Jens Hasskarl

Vismodegib 125

Frank Meiss, Hana Andrlová and Robert Zeiser

Larotrectinib (LOXO-101) 141

Stephanie Berger, Uwe M. Martens and Sylvia Bochum

Palbociclib—The First of a New Class of Cell Cycle Inhibitors 153

Marcus Schmidt and Martin Sebastian

Cobimetinib (GDC-0973, XL518) 177

Hana Andrlová, Robert Zeiser and Frank Meiss

Lenvantinib:​ A Tyrosine Kinase Inhibitor of VEGFR 1-3, FGFR 1-4, PDGFRα, KIT and RET 187

Stefanie Zschäbitz and Carsten Grüllich

Afatinib 199

Helga Wecker and Cornelius F. Waller

Olaparib 217

Sylvia Bochum, Stephanie Berger and Uwe M. Martens

Gefitinib 235

Justyna Rawluk and Cornelius F. Waller

Alectinib 247

M. Herden and Cornelius F. Waller

Osimertinib 257

Umberto Malapelle, Biagio Ricciuti, Sara Baglivo, Francesco Pepe, Pasquale Pisapia, Paola Anastasi, Marco Tazza, Angelo Sidoni, Anna M. Liberati, Guido Bellezza, Rita Chiari and Giulio Metro

© Springer International Publishing AG, part of Springer Nature 2018

Uwe M. Martens (ed.)Small Molecules in OncologyRecent Results in Cancer Research211https://doi.org/10.1007/978-3-319-91442-8_1

Erlotinib

Martin Steins¹  , Michael Thomas¹   and Michael Geißler²  

(1)

Clinic for Thoracic Diseases, University of Heidelberg, Röntgenstr. 1, 69126 Heidelberg, Germany

(2)

Department of Oncology, Gastroenterology and Internal Medicine, Städtische Kliniken Esslingen, Hirschlandstr. 97, 73730 Esslingen, Germany

Martin Steins (Corresponding author)

Email: [email protected]

Michael Thomas (Corresponding author)

Email: [email protected]

Michael Geißler

Email: [email protected]

Abstract

The epidermal growth factor receptor (EGFR) has been implicated in a multiplicity of cancer-related signal transduction pathways like cellular proliferation, adhesion, migration, neoangiogenesis and apoptosis inhibition, all of which are important features of cancerogenesis and tumour progression. Its tyrosine kinase activity plays a central role in mediating these processes and has been intensely studied to exploit it as a therapeutic target. Inhibitors of this pathway have been developed and assessed in trials with significant efficacy in clinical applications. The current review focuses in particular on the clinical data of EGFR tyrosine kinase inhibition in different tumour entities, preferably non-small cell lung cancer and pancreatic cancer with emphasis to the approved small molecule erlotinib. Its clinical applications, evidence-based efficacy and toxicity as well as predictive markers of response are discussed.

Keywords

Epidermal growth factor receptorErlotinibTyrosine kinase inhibitor

1 Introduction

The development of small molecule inhibitors against various tyrosine kinases evoked a new era of antineoplastic agents in cancer therapy besides conventional cytotoxic drugs. The principle of this anticancer treatment is based on the inhibition of receptor tyrosine kinases which are essential components of the intracellular signalling apparatus. Several cellular receptors on the cell surface regulate their signalling via extracellular binding of ligands with consecutive activation of intracellular tyrosine kinase domains and tyrosine phosphorylation. One of these receptors, the epidermal growth factor receptor (EGFR), has gained considerable interest as a possible useful therapeutic target of tumour cells. EGFR is frequently overexpressed in solid tumours and plays a pivotal role in signal transduction pathways involved in cell proliferation, migration, adhesion, angiogenesis induction and apoptosis inhibition. Its overexpression correlates in some tumour entities with disease progression and poorer prognosis (Brabender et al. 2001).

In clinical practice, the uses of the EGFR tyrosine kinase inhibitors (EGFR-TKI) erlotinib (Fig. 1), gefitinib, afatinib and osimertinib have been approved so far for patients with non-small cell lung cancer (NSCLC) for selected indications. In addition, erlotinib combined with gemcitabine has also gained approval for systemic treatment in advanced, non-operable pancreatic carcinoma. The TKI benefit is mainly based on tumour control and overall survival (OS) rather than rapid tumour responses and complete remission rates. In contrast to cytotoxic agents, these responses have been achieved by a specific molecular mechanism disturbing enzyme-mediated signal pathways in cancerogenesis.

Fig. 1

Erlotinib. Chemical formula C22H23N3O4. Molecular mass 393.436 g/ml. Bioavailability 59%, protein binding 95%, half-life 36.2 h, excretion >90% via faeces, 9% via urine

2 Mechanism of Action

EGFR, the primary therapeutic target for erlotinib, belongs to the human epidermal growth factor receptor (HER) family 1, also known as erbB. The structure of this 170-kDa membrane-spanning glycoprotein consists of an extracellular cysteine-rich ligand-binding region, a transmembrane part and the cytoplasmatic tyrosine kinase domain, which is the binding site for kinase inhibitors like erlotinib. Extracellular binding of ligands like the epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-α) renders the receptor from inactive monomers to active homo- or heterodimers through confirmational changes with subsequent phosphorylation of tyrosine residues (Fig. 2). These phosphorylated tyrosine residues serve as binding sites for signal transducers with initiation of a cascade of signalling pathways resulting in tumour growth and progression (Salomon et al. 1995; Alroy and Yarden 1997). In contrast, the small molecule TKIs inhibit the intracellular tyrosine kinase of EGFR by competitive and reversible docking at the ATP binding site of the catalytic domain. Subsequently, the autophosphorylation of the receptor is prevented which results in weakening of the downstream signalling pathways (Hynes and Lane 2005). Therefore, signals induced by extracellular ligand binding cannot be conveyed to the tumour cell nucleus where genes involved in cellular differentiation, proliferation and apoptosis are regulated. Consequences are on the one hand reduced potency for tumour cell migration and invasiveness, on the other hand, induction of apoptosis (Fig. 3). This TKI mechanism differs from the active principle of anti-EGFR antibodies like cetuximab, panitumumab or necitumumab which function via a competitive binding to the extracellular domain. But it explains the striking efficacy of EGFR-TKIs in patients with somatic mutations of the EGFR kinase domain, as it targets a key protein in the tumorigenesis of these patients.

Fig. 2

Function of epidermal growth factor receptor: induction of signal transduction pathways by extracellular binding of ligands with consecutive activation of the receptor tyrosine kinase

Fig. 3

Activity of erlotinib: binding to the intracellular tyrosine kinase domain of the epidermal growth factor receptor and blocking of its ATP binding site. Subsequent disturbance of signal transduction to downstream cascades

3 Non-small Cell Lung Cancer

Lung cancer does not only belong to the most frequent tumour entities in Western countries, it is also in cancer mortality statistics on the first range in men, and on the third (after breast and colorectal cancer) in women. This is the consequence of late detection due to delayed and unspecific symptoms in patients with locally advanced or metastasized disease at the time of first diagnosis. But also in earlier and locally limited tumour stages, the risks for relapse are quite high. Altogether, only 15% of all lung cancer patients survive 5 years after diagnosis despite multimodal therapeutic concepts and new chemotherapeutic agents. Prognosis of the disease still remains serious. Therefore, the development of new agents with different efficacy mechanisms compared to conventional chemotherapy has encouraged the pharmaceutical development. Since 10–15 years, these efforts have led to the emergence of group of TKIs with approvals of the EGFR inhibitors erlotinib, gefitinib, afatinib and osimertinib in advanced NSCLC under certain conditions. In unselected patients, these inhibitors have shown objective tumour responses in 8% up to 19% in particular study groups with prolongation of overall survival of 2 months (Fukuoka et al. 2003; Kris et al. 2003; Pérez-Soler et al. 2004; Shepherd et al. 2005). Especially, this last trial, the BR.21 study of Shepherd et al., has led to the approval of erlotinib in the United States and the European Community in the years 2004 and 2005, respectively, as a TKI for patients with advanced NSCLC who did not respond sufficiently to systemic chemotherapy or suffered a tumour relapse. Approval was based on the data of 731 patients in this randomised, placebo-controlled, multicenter phase III trial performed by the National Cancer Institute of Canada. Oral erlotinib was used as single agent in the second or third therapy line in patients with stage IIIb or IV according to UICC/AJCC. It demonstrated advantage in terms of overall survival and significant release of disease-related symptoms like dyspnoea, pain and cough (Bezjak et al. 2006). Whereas response rates in the erlotinib group comprise only 8.9% with 0.4-month difference in progression-free survival (PFS), the OS—previously defined as the study’s primary end point—was 2 months longer compared with the placebo group (6.7 vs. 4.7 months, hazard ratio 0.70, p < 0.001). According to the prolongation of median survival, 31% of patients treated with erlotinib in this study were alive at 1 year versus 22% in the placebo group. After a head-to-head comparison of erlotinib against afatinib in patients with squamous NSCLC, afatinib additionally has been approved by the European Medicines Agency (EMA) since 2016 for the second-line therapy of this patient group after the failure of previously applicated, platinum-containing chemotherapy (Soria et al. 2015). As independent clinical predictors for survival non-smoking status, female gender, adenocarcinoma histology and Asian ethnicity have been identified in the BR.21 trial (Tsao et al. 2005), which are often related to the presence of activating EGFR gene mutations. EGFR mutations of the tyrosine kinase domain have been found in 10% up to 17% of NSCLC patients, preferably with adenocarcinoma and non-smoking status (Marchetti et al. 2005; Pao and Miller 2005; Zhu et al. 2008).

These mutations, mainly within the exons 19 and 21 (exon 19 deletion, L858R mutation), are the most relevant biologic factors associated with an improved response to first- and second-generation TKIs like erlotinib (Zhu et al. 2008). Various studies also with afatinib and gefitinib have demonstrated that the presence of EGFR gene mutations within the kinase domain of the receptor correlates with TKI sensitivity (Lynch et al. 2004; Paez et al. 2004; Pao et al. 2004). In addition, analyses of EGFR copy numbers by fluorescence in situ hybridization (FISH) in the BR.21 study revealed high EGFR gene copy as a predictive marker of survival benefit from erlotinib.

On the other hand, erlotinib´s efficacy for OS has also been described in patients not presenting the reported clinical characteristics which are associated with the greatest degree of benefit like non-smoking status, female gender or adenocarcinoma histology.

Gefitinib, another EGFR-TKI, was positively associated with clinical benefits, such as tumour response, health-related quality of life and increased survival, in two large randomised phase II studies (IRESSA Dose Evaluation in Advanced Lung Cancer IDEAL-1 and IDEAL-2) in pretreated NSCLC patients (Fukuoka et al. 2003; Natale 2004). However, it did not result in a statistically significant improvement in OS time in comparison with best supportive care in pretreated NSCLC patients of the ISEL (Iressa Survival Evaluation in Lung Cancer) trial, although in preplanned subgroup analyses a significant survival benefit was shown in never-smokers and Asian patients. In the past, the INTEREST trial (Iressa Non-small cell lung cancer Trial Evaluating Response and Survival against Taxotere) and the INVITE trial (open-label, parallel-group study compared gefitinib with vinorelbine in chemotherapy-naïve elderly patients) met their primary endpoints of demonstrating non-inferiority in terms of overall survival for gefitinib in comparison with docetaxel or vinorelbine (Kim et al. 2008; Crinó et al. 2008). Moreover, patients treated with gefitinib experienced a lower treatment-related toxicity and better improvement in quality of life. Nevertheless, a recently performed second-line trial comparing erlotinib and docetaxel showed significantly worse results in OS and PFS for the TKI applied in EGFR wild-type patients (Garassino et al. 2013).

On the other hand, small molecule EGFR-TKIs have class-specific adverse effects mainly including skin reactions like xerosis, acneiform eruption and eczema or mucosa-associated toxicity like diarrhoea. Rash has been reported in up to 75% of patients treated with these agents in phase II/III clinical trials. The rash that occurs with EGFR-targeted agents is generally mild to moderate; severe (grade 3/4) rash is rare (<10–15% in NSCLC trials). In a number of clinical trials, a positive correlation between severity of rash (grade ≥2) and clinical outcome with EGFR-targeted therapy has been demonstrated (Dudek et al. 2006; Pérez-Soler 2006; Cedrés et al. 2009) suggesting rash as a surrogate marker for response. Other side effects have been reported rarely like liver dysfunction or interstitial lung disease (Sandler 2006).

For the first-line treatment of metastatic NSCLC, several phase II and III trials have been conducted utilising EGFR-TKIs in this setting. Patients with advanced NSCLC who are lifelong never-smokers, those with EGFR mutations and/or with bronchioloalveolar cell carcinoma histology seem to have promising efficacy with EGFR-TKI first-line therapy compared with unselected patients receiving the same agents. In fact, based on the data of the I-PASS (Iressa PanASia Study, Mok et al. 2009) the EMA has recommended the approval of gefitinib for mutation-positive NSCLC patients in all treatment lines including upfront therapy. This study performed in never or light former smokers yielded a statistically significant PFS for the gefitinib-treated patient group compared to carboplatin/paclitaxel in first-line therapy of EGFR-mutated NSCLC (HR 0.48, p < 0.0001). Similar therapeutic efficacy could be shown for erlotinib in EGFR mutation-positive Chinese (HR 0.16, p < 0.0001) and Caucasian (HR 0.37, p < 0.0001) patients (Zhou et al. 2011; Rosell et al. 2012). However, in contrast to PFS, no significant differences could be detected in OS when mutation-positive patients were treated with conventional chemotherapy at first and received TKI treatment as second-line therapy (Fukuoka et al. 2011). Nevertheless, quality of life and improvement of symptoms favoured TKI treatment compared to conventional chemotherapy procedures during first-line therapy (Thongprasert et al. 2011; Chen et al. 2013).

Generally, no improvement in survival could be demonstrated in phase III trials when EGFR-TKIs were directly combined with conventional platinum-based doublets, with the exception of subset analysis in non-smokers (Giaccone et al. 2004; Herbst et al. 2005; Gatzemeier et al. 2007). Improvements in response rates and PFS could be shown rather in erlotinib combinations with other targeted agents. In this context, a meta-analysis of 24 phase II/III trials with various erlotinib combination therapies (mainly with targeted drugs) randomised against erlotinib as monotherapy has revealed increased overall response rates and disease control rates as well as longer PFS, but again so far no improvements in OS compared with erlotinib alone (Gao et al. 2017). However, one study, the JO25567 trial, leads to the approval of the anti-vascular endothelial growth factor (VEGF) antibody bevacizumab combined with erlotinib as first-line therapy for EGFR mutation-positive patients (Seto et al. 2014), though grade III or higher adverse events, especially hypertension, increased when using the bevacizumab combination instead of erlotinib alone. But these adverse reactions are known and manageable in anti-angiogenic treatment and did not provoke early drug discontinuation in this trial (Kato et al. 2017).

Future research and development activities try to reduce the risk of TKI failure and define the best sequence therapy in EGFR mutation-positive patients. An important step forward in this respect was the approval of osimertinib in EGFR mutation-positive patients with the acquired T790M resistance mutation (Yang et al. 2017). A subsequent study suggests osimertinib´s application already as first-line therapy in EGFR mutation-positive patients even independent of the presence of T790M mutation (Ramalingam et al. 2017). Further scientific efforts investigate erlotinib in combination with other anti-angiogenic agents like the VEGF-receptor antibody ramucirumab (Garon et al. 2017). And last but not least, combination studies of EGFR-TKIs also with immune-oncologic agents are under investigation.

4 Pancreatic Adenocarcinoma

Pancreatic cancer is the thirteenth most common cancer and the eighth leading cause of cancer death worldwide (Parkin et al. 2005). Only few patients with pancreatic cancer (15–20%) present with resectable disease, where surgery offers a chance of cure. Following resection for operable pancreatic cancer, the median disease-free survival interval is 13.4 months for patients treated with adjuvant gemcitabine and 6.9 months for untreated patients. The longer median disease-free survival time associated with adjuvant gemcitabine has translated into a significant 5-year overall survival (OS) advantage (21 vs. 9%) (Neuhaus et al. 2008). A much higher percentage of patients, however, present with metastatic disease (40–45%) or unresectable locally advanced disease (40%). These disease stages are characterised by median survival times of 3–6 or 8–12 months, respectively. In locally advanced, unresectable disease, patients typically receive 5-fluorouracil (5-FU)-based chemoradiation or gemcitabine chemotherapy alone. The benefits of chemoradiation over chemotherapy alone in locally advanced disease have not been well established. Erlotinib has been evaluated in two phase I studies using a multimodal chemoradiation approach. One study examined erlotinib plus gemcitabine and paclitaxel plus radiation followed by maintenance with erlotinib and reported a partial response rate of 46% and median survival time of 14 months (Iannitti et al. 2005). These results are supported by the other trial of erlotinib plus gemcitabine and radiation for patients with locally advanced, unresectable pancreatic cancer (Duffy et al. 2008). Single-agent gemcitabine is the standard first-line agent for the treatment of advanced inoperable pancreatic cancer with a marginally superior clinical benefit and survival compared with fluorouracil (FU) approximately 10 years ago (Burris et al. 1997). A number of randomised controlled trials performed over the last decade have aimed to demonstrate superiority of alternative cytotoxic agents and cytotoxic combinations over gemcitabine alone with mostly disappointing results. A recent meta-analysis, however, suggested a survival benefit with a reduction of 9% in risk of death for gemcitabine-based combination chemotherapy (14 trials, 4.060 patients; HR = 0.91; 95% CI, 0.85–0.97) (Sultana et al. 2007). In parallel, our understanding of the underlying genetic and molecular abnormalities that drive the development of pancreatic cancer has expanded significantly over the last decade (Schneider et al. 2008). Alterations to oncogenes and tumour suppressor genes, such as KRas, TP53 and p16INK4, are thought to play a critical role in the development of pancreatic cancer. In addition, expression of the human epidermal growth factor receptor (HER-1/EGFR) in pancreatic cancer cells is associated with the stimulation of tumour cell proliferation, poor disease outcomes and lower sensitivity to chemotherapy (Birk et al. 1999; Nicholson et al. 2001; Xiong and Abbruzzese 2002). These observations have allowed for the rational development of targeted therapies for this hard-to-treat disease. However, with the exception of erlotinib, the completed phase III trials have not confirmed an important clinical benefit (Van Cutsem et al. 2004; Moore et al. 2003; Bramhall et al. 2002; Moore et al. 2007; Kindler et al. 2010; Philip et al. 2007; Shapiro et al. 2005). Based on a phase III randomised, placebo-controlled trial (NCIC-CTG study), erlotinib in combination with gemcitabine received US Food and Drug Administration approval as treatment for chemotherapy-naïve locally advanced and metastatic pancreatic cancer in 2005 (Moore et al. 2007). The EMA subsequently licensed erlotinib in combination with gemcitabine restricted for the treatment of patients with metastatic pancreatic cancer only because there was no survival benefit in the locally advanced stage (HR 0.94; 0.63–1.39). In total, 569 patients were randomly assigned in a 1:1 ratio to receive standard gemcitabine plus erlotinib (100 mg/day orally) or gemcitabine plus placebo in this double-blind, international phase III trial. The primary endpoint of a longer OS time was achieved statistically with an HR of 0.82 (95% CI, 0.69–0.99; p = 0.038) and a median survival duration of 6.24 versus 5.91 months. Secondary endpoint results from this trial showed a 1-year survival rate of 23% in the erlotinib plus gemcitabine arm, versus 17% with gemcitabine monotherapy (p = 0.023). The progression-free survival (PFS) duration was also significantly longer with the combination regimen (3.75 vs. 3.55 months; HR, 0.77; p = 0.004). Objective response rates were not significantly different between the arms, although more patients on erlotinib had disease stabilisation. The clinical significance of these efficacy results has been questioned by several investigators and treating physicians. A review of toxicities may further discourage the use of gemcitabine plus erlotinib. Patients receiving erlotinib and gemcitabine experienced higher frequencies of rash (72%), diarrhoea (56%), infection (43%) and stomatitis (23%), generally grade 1 or 2. Grade 3 or 4 toxicities were similar, except for diarrhoea and cutaneous rash, which were more frequent with the two-drug combination (6% each). The six protocol-related deaths were all in the erlotinib–gemcitabine arm. Two were attributed to treatment complications (interstitial pneumonitis and sepsis), and four were attributed to a combination of cancer and protocol treatment complications (interstitial pneumonitis, sepsis, cerebrovascular accident and neutropenic sepsis). Interstitial lung disease was observed in seven patients receiving erlotinib plus gemcitabine and in one patient receiving placebo plus gemcitabine. In fact, there may be an interaction between gemcitabine and erlotinib contributing to increased pulmonary toxicity (Boeck et al. 2007).

An unplanned analysis of the NCIC-CTG study suggested the development of rash as a predictive marker for response to therapy with erlotinib. Patients with advanced pancreatic cancer who experienced grade 2 rash or higher (n = 102) had a reported median survival time of 10.5 months and a 1-year survival rate of 43%. Rash development was linked to overall and progression-free survival, and these correlations increased with grade (grade 1 vs. no rash: hazard ratio (HR) 0.47, p < 0.001; grade 2 or more vs. no rash: HR 0.29; p < 0.001). These data were supported by a combined analysis from two large phase III studies (National Cancer Institute of Canada Clinical Trials Group Studies BR.21 in non-small cell lung cancer and NCIC-CTG PA.3 in pancreatic cancer). Presence of rash strongly correlated with overall survival in both studies. Similar results were observed for PFS (Wacker et al. 2007). In addition, a retrospective exploratory analysis of the phase III AVITA study (gemcitabine + erlotinib + placebo vs. gemcitabine + erlotinib + bevacizumab) confirmed the results of the NCIC-CTG study (Van Cutsem et al. 2009). In the placebo arm, overall survival was only 4.3 months in patients without rash compared to 7.1 and 8.3 months in patients with grade 1 and grade >1 rash, respectively (p < 0.0001). In the NCIC-CTG study, however, rash was also present in 18% of placebo-taking patients with median survival 8.2 months (Moore et al. 2007). Placebo-taking patients who did not develop rash had a median survival of 4.7 months. In the combined treatment arm (gemcitabine plus erlotinib), 81% of the patients developed a rash, compared with 30% of patients in the control group. Since no reliable molecular predictive biomarker exists for the medical treatment of pancreatic cancer physicians and patients should view rash development as a positive event indicative of greater likelihood of clinical benefit. It is important to understand that the development of rash following erlotinib treatment is not an intrinsic effect of erlotinib itself but more likely correlated to individual differences in drug exposure, the integrity of the immune system or EGFR polymorphisms (Saif et al. 2008; Lynch et al. 2007). Further studies are required to identify patients most likely to develop rash and to determine if dose escalation to induce rash can improve efficacy.

How shall we use rash in daily practice? It has been suggested that the rash clinically improves with continuation of treatment. Nevertheless, severe rash development may be a determining cause of treatment discontinuation by patients on erlotinib outside clinical trials. If rash development is in fact a surrogate marker for treatment success, then patients discontinuing treatment are potentially stopping a life-prolonging treatment. This is why it is crucial to exploit all means available in the treatment of the erlotinib-induced skin rash, in order to discourage patients from stopping it. Assessing the tumour response according to RECIST or WHO criteria remains the standard of care independent on the development of rash because there may exist responders without rash and, contrary, patients with a tumour progress despite the development of rash.

Since it is unclear if every patient with advanced pancreatic cancer has to be treated with a combination chemotherapy of gemcitabine and erlotinib, there may be a rationale for sequential therapeutic strategies. Several drugs have been examined as a second-line therapy (Kulke et al. 2007). The most promising chemotherapeutic regimen may be the OFF-protocol consisting of Oxaliplatin, 5-FU and FA. In a randomised phase III study, this combination chemotherapy resulted in a significant survival advantage compared to 5-FU/FA alone (Pelzer et al. 2008). Another option in gemcitabine-pretreated patients would be the combination of erlotinib and capecitabine. In one single-arm phase II study with 32 patients, the median progression-free survival time was 3.4 months, and the median overall survival time was 6.5 months (Kulke et al. 2007). One-year overall survival was 26%. In contrast, disappointing results were reported in a retrospective analysis of 13 patients treated with single-agent erlotinib (Epelbaum et al. 2007). No responses and a median time to progression (TTP) of only 1 month were observed.

At the current time, gemcitabine, either alone or in combination with erlotinib, remains the only approved first-line treatment for advanced pancreatic carcinoma. Multiple trials are planned that will employ new and novel targeted and biological agents together with the search for predictive biomarkers.

5 Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the third largest cause of cancer-related death third to lung and colon cancers (Parkin et al. 2005). The incidence has increased in the Western world over the past 20 years primarily as a result of the prevalence of hepatitis C virus infection (El-Serag and Mason 1999). Management of HCC is complex and is guided by the Barcelona Liver Clinic (BCLC) staging system, which has important prognostic value (Llovet et al. 1999). The BCLC system is conceptually useful, because it helps to integrate liver function and tumour features into a classification that is meaningful from a standpoint of treatment options. For example, BCLC C patients are those best suited for systemic therapies or clinical trials. Systemic chemotherapy, however, has largely been disappointing in terms of palliation or cure. Cytotoxic chemotherapy has been shown to provide no survival benefit. With that background in mind, the multitargeted tyrosine kinase inhibitor sorafenib was studied in HCC. Patients with advanced stage HCC who were not candidates for, or who had disease progression after locoregional therapy, were enrolled in the Sorafenib Hepatocellular Carcinoma Assessment Randomised Protocol (SHARP) trial (Llovet et al. 2008). The 1-year survival for the sorafenib group was 44 and 33% for the placebo group. The median survival for the sorafenib group was 10.7 months from enrollment compared to 7.9 months for those who received placebo. The survival benefit appeared to be correlated to a 2.7-month delay in radiologic progression (5.5 months for the sorafenib group vs. 2.8 months for the placebo group). A recent phase III study of sorafenib versus placebo in Asian patients reported a similar increase in survival (6.2 vs. 4.1 months) (Cheng et al. 2009). Sorafenib is now considered to be the standard medical treatment for patients with Child-Pugh stage A cirrhosis within the BCLC stage 3 group.

Epidermal growth factor receptor (EGFR) is frequently overexpressed in HCC (Buckley et al. 2008). In a phase II study, erlotinib was evaluated in 38 patients with unresectable or metastatic HCC (Philip et al. 2005). Most frequent grade 3 to 4 toxicities were skin rash (13%), diarrhoea (8%) and fatigue (8%). There was a correlation between the severity (grade 3 or higher) of toxicity and Child-Pugh classification: only 22% of the Child-Pugh A patients experienced severe toxicity compared to 70% of Child-Pugh B patients (p = 0.02). 32% of the patients were progression-free after 24 weeks. The overall confirmed response rate was only 9%. Seventeen patients (50%) achieved stabilisation of disease for a median of 3.8 months. There was no correlation between response and EGFR status. The median overall survival time was 13 months, with a probability of 33% of patients alive at 18 months from entry into the study. In a second phase II study, 40 HCC patients were treated with erlotinib 150 mg daily for 16 weeks (Thomas et al. 2007). There were no complete or partial responses; however, 17 of 40 patients achieved stable disease at 16 weeks of continuous therapy. The PFS at 16 weeks was 43%, and the median overall survival was 43 weeks (10.75 months). No patients required dose reductions of erlotinib. Again, no correlation between EGFR expression and outcome was found.

In contrast to lung cancer, the gain of function in EGFR signalling in HCC seems mediated through increase in ligand–receptor interaction, rather than by point mutations or amplifications (Llovet and Bruix 2008). Erlotinib treatment of HCC might inhibit the mitogen-activated protein (MAP)-kinase pathway and signal transducer of activation and transcription (STAT)-mediated signalling resulting in an altered expression