Erlotinib and bevacizumab in patients with recurrent or metastatic squamous-cell carcinoma of the head and neck: a phase I/II study

Abstract

Background: Epidermal growth factor receptor (EGFR) is a validated target in squamous-cell carcinoma of the head and neck, but in patients with recurrent or metastatic disease, EGFR targeting agents have displayed modest efficacy. Vascular endothelial growth factor (VEGF)-mediated angiogenesis has been implicated as a mechanism of resistance to anti-EGFR therapy. In this multi-institutional phase I/II study we combined an EGFR inhibitor, erlotinib, with an anti-VEGF antibody, bevacizumab.

Methods: Between April 15, 2003, and Jan 27, 2005, patients with recurrent or metastatic squamous-cell carcinoma of the head and neck were enrolled from seven centres in the USA and were given erlotinib (150 mg daily) and bevacizumab in escalating dose cohorts. The primary objectives in the phase I and II sections, respectively, were to establish the maximum tolerated dose and dose-limiting toxicity of bevacizumab when administered with erlotinib and to establish the proportion of objective responses and time to disease progression. Pretreatment serum and tissues were collected and analysed by enzyme-linked immunosorbent assay and immunofluorescence quantitative laser analysis, respectively. This study was registered with ClinicalTrials.gov, number NCT00055913.

Findings: In the phase I section of the trial, ten patients were enrolled in three successive cohorts with no dose-limiting toxic effects noted. 46 patients were enrolled in the phase II section of the trial (including three patients from the phase I section) on the highest dose of bevacizumab (15 mg/kg every 3 weeks). Two additional patients were accrued beyond the protocol-stipulated 46, leaving a total of 48 patients for the phase II assessment. The most common toxic effects of any grade were rash and diarrhoea (41 and 16 of 48 patients, respectively). Three patients had serious bleeding events of grade 3 or higher. Seven patients had a response, with four showing a complete response allowing rejection of the null hypothesis. Median time of overall survival and progression-free survival (PFS) were 7.1 months (95% CI 5.7-9.0) and 4.1 months (2.8-4.4), respectively. Higher ratios of tumour-cell phosphorylated VEGF receptor-2 (pVEGFR2) over total VEGFR2 and endothelial-cell pEGFR over total EGFR in pretreatment biopsies were associated with complete response (0.704 vs 0.386, p=0.036 and 0.949 vs 0.332, p=0.036, respectively) and tumour shrinkage (p=0.007 and p=0.008, respectively) in a subset of 11 patients with available tissue.

Interpretation: The combination of erlotinib and bevacizumab is well tolerated in recurrent or metastatic squamous-cell carcinoma of the head and neck. A few patients seem to derive a sustained benefit and complete responses were associated with expression of putative targets in pretreatment tumour tissue.

Figure 1

Study flow diagram. NE = non-evaluable, MTD = maximum tolerable dose.

Figure 2

(A) Overall survival (n=48). (B) Progression-free survival (n=48). Grey lines indicate 95% pointwise confidence intervals. Vertical tics denote censored observations.

Figure 3

(A) Overall survival in first-line patients (n=23). (B) Overall survival in second-line patients (n=23). (C) Progression-free survival in first-line patients (n=23). (D) Progression-free survival in second-line patients (n=23). Grey lines indicate 95% pointwise confidence intervals. Vertical tics denote censored observations.

Figure 4

(A) Representative laser scanned images show high expression of phosphorylated VEGFR2/total VEGFR2 in CR compared to non-CR patients (pVEGFR2 stained red, VEGFR2 stained green). (B) High expression of phosphorylated EGFR/total EGFR in endothelial cells in CR vs. non-CR patients (pEGFR stained green, CD31 stained red). (C) Pre-treatment mean fluorescent intensity (MFI) of pVEGFR2/VEGFR2 (p=0.036) and EC pEGFR/EGFR (p=0.036) quantified by laser scanning cytometry in CR vs. non-CR patients.

Figure 5

Correlation between (A) pVEGFR2/VEGFR2 (p=0.007) and (B) EC pEGFR/EGFR (p=0.008) ratios and maximal reduction in tumor size (n=11). Complete responses were scored as −100% in tumor size change.

Figure 6

Kaplan-Meier curves for the association between progression-free survival and (A) pVEGFR2/VEGFR2 (p=0.32) or (B) EC pEGFR/EGFR (p=0.12) ratios. Solid line represents subjects with a respective ratio at or above the median (n=6). Dotted line represents subjects with a respective ratio below the median (n=5).