1. Consorzio Interuniversitario Nazionale per la Bio-Oncologia Dott.ssa Alessandra Santomaggio Oncologia medica P.O. San Salvatore Università Degli Studi DellAquila 28 novembre 2008

2. la tossicità del 5-FU è maggiore nellanimale da laboratorio quando lanimale è nella fase di attività rispetto alla fase di riposo incremento della attività a metà notte, nelle cellule mononucleate periferiche dell'uomo, della diidropirimidina deidrogenasi (DPD) riduzione nell'uomo, della sintesi del DNA da parte delle cellule del midollo osseo e della mucosa orale e gastrointestinale, nella prima metà della notte (tra le ore 24.00 e le ore 4.00) rispetto alla prima metà della fase di attività

3. Chronomodulated versus fixed-infusion-rate delivery of ambulatory chemotherapy with oxaliplatin, fluorouracil, and folinic acid (leucovorin) in patients with colorectal cancer metastases: a randomized multi-institutional trial. Levi FA, Zidani R, Vannetzel JM, Perpoint B, Focan C, Faggiuolo R, Chollet P, Garufi C, Itzhaki M, Dogliotti L, et al. J Natl Cancer Inst. 1994 Nov 2;86(21):1608-17. CRONOFLAT 5-FU 600-700; l-OHP 20-25; AF 300 5 gg 3 w 5-FU 600-700; l-OHP 20-25; AF 300 5 gg 3 w 45 patients47 patients G3-4 Stomatitis 18%G3-4 Stomatitis 89% HF s. 4%HF s. 11% 5-FU median dose 7005-FU median dose 500 RR 53%; TTP 11; OS 19RR 32%; TTP 8; OS 14.9

4. CRONOFLAT 5-FU 700; l-OHP 25; AF 300 5 gg 3 w 5-FU 700; l-OHP 25; AF 300 5 gg 3 w 93 pazienti G3-4 Stomatitis § 14%G3-4 Stomatitis § 76% Neurotoxicity 16%Neurotoxicity 31% 5-FU median dose 7005-FU median dose 500 RR 51%*; TTP 10; OS 16RR 29%*; TTP 8; OS 17 Randomised multicentre trial of chronotherapy with oxaliplatin, fluorouracil, and folinic acid in metastatic colorectal cancer. International Organization for Cancer Chronotherapy. Levi F, Zidani R, Misset JL. Lancet. 1997 Sep 6;350(9079):681-6. * p 0,003 § p < 0.0001

5. 4 AM 10 AM 10 PM 4 PM 5-FU 22-h continous infusion 5-FU bolus 5-FU 2800 mg/mq 46-h continous infusion LVLV LVLV LVLV 5-FU continous infusion 12-h Timed Flat Infusion TFI/5-FU

7. 1 2 3 4 CPT-11 180 mg/m 2 5-FU 600-1200 mg/m 2 /d h day 22 10 22 10 22 10 22 10 15 16 17 18 CPT-11 180 mg/m 2 Ficorella C Oncol Rep 2006 22 10 22 10 22 10 22 10

11. As Treated analysis (%) n. assessable patients 24/33 CR 3 (12,5) PR 6 (25) SD 5 (21) PD 10 (41,5) AsT Overall Response Rate (ORR) 37,5% (α0.05; CI 20) AsT Disease Control Rate 58,5%

12. 12 At median follow-up of 17 months, we observed: Median Time to Progression (TTP)* 10 months (Range months 2-28+) Median Overall Survival (OS)* 25 months (Range months 3 - 42) *calculated with method of Kaplan and Meier

14. As Treated analysis (%) n. assessable patients 37/52 CR 3 (8) PR 12 (32) SD 12 (32) PD 10 (28) AsT Overall Response Rate (ORR) 40% (α0.05; CI 16) AsT Disease Control Rate 72%

15. 15 At median follow-up of 19 months, we observed: Median Time to Progression (TTP)* 10 months (Range months 2-32+) Median Overall Survival (OS)* 21 months (Range months 3 – 47+) *calculated with method of Kaplan and Meier

16. La migliore tollerabilità di L-OHP si verifica a 16 HALO (hours after light onset) negli animali trattati

17. 4 AM 10 AM 10 PM 4 PM 5-FU 22-h continous infusion 5-FU bolus 5-FU 2800 mg/mq 46-h continous infusion LVLV LVLV LVLV 5-FU continous infusion 12-h Timed Flat Infusion TFI/5-FUl-OHP

18. 22 10 22 10 1 2 CPT-11 180 mg/m 2 5-FU 800-1300 mg/m 2 /d h day 15 22 10 22 10 8 9 l-OHP 70-80 mg/m 2 22 10 22 10 15 16 CPT-11 180 mg/m 2 15 15 22 10 22 10 22 23 l-OHP 70-80 mg/m 2 Submitted

19. Total N. (%) No. of patients 36 Sex M/F 22/14 Age, years median range > 65 years 62 39-74 14 (39) WHO Performance Status 0 1-2 30 (83) 6 (17) Primary tumor colon rectum 26 (72) 10 (28) No. of involved sites 1 2 26 (72) 10 (28) Sites of metastases liver lung lynph nodes local Other 22 (61) 8 (22) 7 (19) 4 (11) 6 (17) Liver metastases single Multiple 3 (8) 19 (53) Previous adjuvant chemotherapy: FA/5-FU bolus 5-FU bolus + i.c. Irinotecan/5FU 9 (25) 6 (17) 2 (6) 1 (3) Previous radiotherapy: RT alone RT+CT (5-FU i.c.) 2 (6) - 2 (6)

20. Dose levels CPT11 (mg/m 2 d1,15)- l-OHP (mg/m 2 d8,22)- 5-FU (mg/m 2 /d d1-2, 8-9, 15- 16, 22-23) No. patients a (new patients) No. cycles No. Patients with DLT b /total patients (%) No. New patients with DLT/new patients (%) No. cycles with DLT/total cycles (%) DLTs I180-70-700 2 (2) 2---- II180-70-800 3 (1) 3---- III180-70-900 3 (0) 3---- IV180-80-900 7 (4) 121/7 (14%)-1 (8%)G3 Diarrhea V180-80-1000 11 (6) 30 3/11 (27%) 3/6 (50%)3 (10%) G3 Diarrhea G1 Fever with delay > 2 weeks G3 Hypotension a intra- and inter-patient dose escalation ( Simon R. et al., JNCI 1997) b dose-limiting toxicity

21. Adverse events NCI-CTC grade (%) per Cycles NCI-CTC grade (%) per Patients 12341234 Nausea 30 (24) 12 (9,5) -- 10 (43) 6 (26) -- Vomiting 13 (10) 11 (9) -- 7 (30) 6 (26) -- Diarrhea 18 (14) 18 (14) 11 (9) - 3 (13) 8 (35) 8 (35) - Stomatitis 16 (13) 1 (1) -- 6 (26) 2 (9) -- Asthenia 33 (26) 16 (13) 1 (1) - 9 (39) 9 (39) 1 (4) - Neurotoxicity 54 (43) 6 (5) 1 (1) - 14 (61) 2 (9) 1 (4) -

22. Adverse events NCI-CTC grade (%) per Cycles NCI-CTC grade (%) per Patients 12341234 Anemia 13 (10) 3 (2) -- 5 (22) 3 (13) -- Leucopenia 19 (15) 17 (13) -- 3 (13) 8 (35) - 1 (4) Neutropenia 10 (8) 21 (17) 7 (5.5) 1 (1) 3 (13) 6 (26) 3 (13) 1 (4) Thrombocytopenia 10 (8) 4 (3) -- 3 (13) 3 (13) --

23. Intention to treat analysis (%) Assessable patients (%) n. patients 3330 CR 2 (6) 2 (6.7) PR 21 (63.6) 18 (60) SD 3 (9) 3 (10) PD 7 (21.2) 7 (23.3) ITT Overall Response Rate (ORR) 69.6% (α0.05; CI 16) ITT Disease Control Rate 78.6% AsT Overall Response Rate (ORR) 66.7% (α0.05; CI 17) AsT Disease Control Rate 76.7%

24. 24 With a median follow-up of 19 months (range 1-31), we observed: Median Time to Progression (TTP)* 12 months (Range months 3+ - 61+) Median Overall Survival (OS)* 20 months (Range months 3+ - 61+) *calculated with method of Kaplan and Meier

25. AutoreFasePts PDI CPT-11 mg/m 2 /w PDI OXP mg/m 2 /w PDI 5-FU mg/m 2 /w LV mg/m 2 G3-4 diarrea (% of pts) Neutropenia febbrile (% of pts) RR % Falcone 2002 I4287,5501900 48h ic200211471.4 Ychou 2003 I349042,5 400 b + 600 22 h ic or 400 b +2400 46 h ic 200 or 400 25-2825-14-* Goetz 2003 I3550 or 5817 or 28213 b or 320 b2016,6--* Abad 2004 I187542,51125 48 h ic-33-77 Cals 2004 I3440322400 24 h ic--16,650 # Gil-Delgado 2004 I349042,5 400 b + 600 22 h ic 20012,5 44 Present Study I-II299040 1800 TFI -37,5-57 Bécourarm 2001 II324521,2 400 b + 600 22h ic 20019136#6# Calvo 2002 II2662,5301300 24 h ic50034,5-69.2 Souglakos 2002 II317532,5 400 b + 600 22h ic 20032658.1 Garufi 2003 II356026.7 § 933 § 150 § 28-22.9 # Rosati 2004 II404432,5 1150 or 900 48 h ic 15072,2-57.5 Masi 2004 II3282,542,51600 48 h ic200163472

26. 22 10 22 10 1 2 CPT-11 160 mg/m 2 Bevacizumab 5 mg/kg 5-FU 900 mg/m 2 /d h day 15 22 10 22 10 8 9 l-OHP 60-70-80 mg/m 2 22 10 22 10 15 16 CPT-11 160 mg/m 2 Bevacizumab 5 mg/kg 15 22 10 22 10 22 23 l-OHP 60-70-80 mg/m 2

27. Total N. (%) No. of patients 46 Sex M/F28/18 Age, years median range > 65 years 64 40-73 23 (50) WHO Performance Status 0 1-2 44 (96) 2 (4) Primary tumor colon rectum 22 (48) 24 (52) No. of involved sites 1 2 26 (57) 20 (43) Sites of metastases liver lung lynph nodes local Other 31 (67) 11 (24) 17 (37) 9 (19) 5 (11) Liver metastases single Multiple 10 (22) 21 (46) Previous adjuvant chemotherapy: FA/5-FU bolus Capecitabine Folfox4 9 (19) 4 (9) 1 (2) 4 (9) Previous radiotherapy: RT alone RT+CT (5-FU i.c.) RT+CT (XELOX) 6 (13) 2 (4) 3 (6) 1 (2)

28. Dose levels CPT11 (mg/m 2 d1,15)- Bevacizumab (mg/kg d1,15)- l-OHP (mg/m 2 d8,22)- 5-FU (mg/m 2 /d d1-2, 8-9, 15-16, 22-23) No. patients a (new patients) No. cycles No. Patients with DLT b /total patients (%) No. New patients with DLT/new patients (%) No. cycles with DLT/total cycles (%) DLTs I900-160-5-60 9 (9) 12 1/9 (11%) 1/9 (11%) 1/12 (8%) G3 Diarrhea II900-160-5-70 11 (3) 110/110/30/11- III900-160-5-80 14 (3) 41 1/14 (7%) 0/3 1/41 (2%) G3 Mucositis G2 Diarrhea + G2 Hypoalbumin. a intra- and inter-patient dose escalation ( Simon R. et al., JNCI 1997) b dose-limiting toxicity

29. PatientsCycles Number46196 NCI-CTC Grade12341234 Nausea (%)22 (48)12 (26)3 (7)-66 (34)19 (10)4 (2)- Vomiting (%)9 (20)6 (13)2 (4)-18 (9)9 (5)2 (1)- Diarrhea (%)19 (41)13 (28)11 (24)-58 (30)26 (13)12 (6)- Hypoalbuminemia (%)2 (4)1 (2)--2 (1)1 (0.5)-- Constipation (%)15 (33)1 (2)--20 (10)1 (0.5)-- Stomatitis/mucositis (%)14 (30)2 (4)3 (6.5)-24 (12)3 (1.5) - Erythema (%)1 (2)- -3 (1.5)-1 (0.5)- Asthenia (%)11 (24)19 (41)2 (4)-32 (16)30 (15)2 (1)- Neurotoxicity (%)31 (67)5 (11)--101 (52)6 (3)-- Hypertension (%)12 (26)4 (9)1 (2)-22 (11)4 (2)1 (0.5)- Hypotension (%)1 (2)---1 (0.5)--- Hematuria (%)2 (4)1 (2)--3 (1.5)1 (0.5)-- Gengival recession/gengivitis (%)7 (15)---10 (5)--- Rhinitis (%)32 (70)---86 (44)--- Epistaxis (%)25 (54)2 (4)--59 (30)--- HFS (%)1 (2)---1 (0.5)--- Headache (%)5 (11)---8 (4)--- Hypokalemia (%)3 (6.5)1 (2)--2 (1)-1 (0.5)- Hypertransaminasemy (%)3 (6.5)1 (2) 7 (15)3 (1.5)1 (0.5) Hyperpigmentation (%)6 (13)2 (4)--11 (6)2 (1)-- Fever without infection (%)10 (22)---11 (6)--- Alopecia (%)3 (6.5)8 (17)2 (4)-7 (4)12 (6)5 (3)-

30. PatientsCycles Number46196 NCI-CTC Grade12341234 Anemia (%)7 (15)1 (2)--13 (7)1 (0.5)-- Leucopenia (%)12 (26)11 (24)--37 (19)16 (8)-- Neutropenia (%)8 (17)11 (24)4 (9)-28 (14)18 (9)7 (4)- Trhombocitopeny (%)5 (11)1 (2)--14 (7)1 (0.5)--

31. Intention to treat analysis (%) As Treated analysis (%) n. assessable patients 3935 CR 2 (5) 2 (6) PR 30 (77) 27 (77) SD 2 (5) 2 (6) PD 5 (13) 4 (11) CR complete response; PR partial response; SD stable disease; PD progressive disease 1 pt lost to follow-up; 6 pts had not received at least 3 cycles of treatment; 4 pts evaluated after 2 cycles of treatment

32. Intention to treat analysis (%) As Treated analysis (%) n. assessable patients 3935 CR 2 (5) 2 (6) PR 30 (77) 27 (77) SD 2 (5) 2 (6) PD 5 (13) 4 (11) ITT Overall Response Rate (ORR) 82% (α0.05; CI 12) ITT Disease Control Rate 87% AsT Overall Response Rate (ORR) 83% (α0.05; CI 13) AsT Disease Control Rate 89%

33. BEV5-FUCPT-11L-OHP Mediana (range) Media (C.I. α 0,05) Mediana (range) Media (C.I. α 0,05) Mediana (range) Media (C.I. α 0,05) Mediana (range) Media (C.I. α 0,05) DI/ciclo mg/m 2 (Kg)/w 2,25 (1-2,5) 2,1 ( 0,06) 1575 (720-1800) 1519 ( 47,1) 72 (25-80) 68 ( 2,1) 35 (14-40) 33 (1,05) DI/pz mg/m 2 (Kg)/w 2,1 (1,7-2,5) 2 ( 0,08) 1530 (955-1800) 1514 ( 66) 67 (50-80) 68 ( 2,9) 33 (21-38) 32 (1,45) 33 BEV84% of projected D.I. 5-FU85% of projected D.I. CPT-1184% of projected D.I. OXP82% of projected D.I.

34. 34 With a median follow-up of 12 months (range 1-31), we observed: Median Progression Free Survival (PFS)* 12 months (Range months 1+ - 30+) Median Overall Survival (OS)* 28 months (Range months 1+ - 31+) *calculated with method of Kaplan and Meier

35. 35 Total N. (%) No. of patients6/46 (13) Sites liver single multiple liver and lung primary tumor and lymph nodes 3/6 (50) 2/3(67) 1/3 (33) 1/6 (17) 2/6 (33)

37. DTX 80-85 mg/mq 5-FU 700-900 mg/mq/d 22 10 22 10 22 10 22 10 22 10 1234512345 day h 10pm-10amTFI traces the 12h circadian-timed infusion of 5-FU (10PM-10AM with maximum delivery at 4AM) and may contribute to increase its tolerability, using an easier administration than the chromodulated infusion.

41. As Treated analysis (%) n. assessable patients 13/14 CR 2 (15) PR 6 (46) SD 3 (24) PD 2 (15) AsT Overall Response Rate (ORR) 61% (α0.05; CI 28) AsT Disease Control Rate 82%

42. Recommended DoseMTD a Authorpts5-FU schedule docetaxel mg/m 2 5-FU mg/m 2 /d docetaxel mg/m 2 5-FU mg/m 2 /d DLT b Petit [22]37bolus60 d1 every 4 w 300 d1-3 or d1-5 every 4 w 75 d1300 d1-3mucositis neutropenia Ando [23]19C.I.50 d1 every 3 w 500 d1-5 every 3 w 60 d1500 d1-5diarrhea neutropenia Lortholary [24]32C.I.85 d1 every 3 w 750 d1-5 every 3 w 100 d1750 d1-5stomatitis Present study1412-h C.I.85 d1 every 3 w 800 d1-5 every 3 w 85 d1900 d1-5diarrhea a MTD maximum-tolerated dose b DLT dose-limiting toxicity

44. n (%) Number of patients Median age Range 18(100) 59 48-74 WHO performance status: 0 1 15(83) 3(16) Surgery: Mastectomy Lumpectomy 6(33) 12(68) Adjuvant therapy: Chemotherapy with anthracyclines Chemotherapy without anthracyclines Hormonal therapy Radiotherapy 9(53) 5(30) 7(40) Previous metastatic breast cancer therapy: Hormonal therapy2(13) Disease sites: Soft tissue and skin Liver Lung and pleura Bone Brain 1(6) 9(50) 1 2(70) 2(11) Number of organs involved: 1 2 2(12) 15(83)

45. Cycles 141 Patients 18 Grade12341234 Fever (%)-4 (3)---3 (23)-- Neutropenia (%)1 (1)12 (8)24 (17)29 (20)-1 (5)2 (11)13 (76) Leucopenia (%)4 (3)20 (16)28 (19)8 (5)1 (5) 9 (52)5 (29) Anemia (%)8 (6)1 (1)--4 (23)1 (5)-- Nausea (%)11 (9)5 (4)--4 (23) -- Vomiting (%)3 (2)2 (1)--2 (11) -- Diarrhea (%)4 (3)2 (1)--4 (23)2 (11)-- Stomatitis (%)7 (5) 3 (2)1 (1)2 (11)4 (23)3 (17)1 (1) Neurotoxicity (%)2 (1)---2 (11)--- Dermatitis (%)-2 (1)---2 (11)-- Fluid retention (%)5 (4)----3 (17)-- Asthenia (%)1 (1)----1 (5)-- Cardiotoxicity (%)-------- 2 cases (8%) of thrombosis related to the venous access dev

46. As Treated analysis (%) n. assessable patients 13/14 CR 2 (15) PR 6 (46) SD 3 (24) PD 2 (15) AsT Overall Response Rate (ORR) 61% (α0.05; CI 28) AsT Disease Control Rate 82%

47. 47 We observed: Median Progression Free Survival (PFS)* 10 months (Range months 4 - 28) Median Overall Survival (OS)* 25 months (Range months 4 - 46+) *calculated with method of Kaplan and Meier

48. Grazie per lattenzione