【作者】 周建娅；

【导师】 周建英；

【作者基本信息】 浙江大学 ， 内科学， 2010， 博士

【摘要】 研究目的:表皮生长因子受体（Epidermal Growth Factor Receptor,EGFR）属于Ⅰ型生长因子家族（ERRB家族）,具有酪氨酸激酶活性,在非小细胞肺癌肿瘤组织上有广泛表达,从而调控肿瘤细胞的增殖、分化、凋亡和肿瘤的转移、血管增生及化疗药的耐药。其中采用EGFR酪氨酸激酶抑制剂（Epidermal Growth Factor Receptor-TyrosineKinase Inhibitor,EGFR-TKI）抑制EGFR活性是目前抗癌药研究中最受瞩目的领域。吉非替尼和厄洛替尼是目前已上市的EGFR-TKI,大型临床试验表明约9-26%的晚期非小细胞肺癌病人（Non Small Cell Lung Cancer,NSCLC）可以从中受益。盐酸埃克替尼（Icotinib Hydrochloride,BPI-2009H）是从化学库中筛选出的新的化学小分子EGFR-TKI。本研究在细胞水平,评价其对肺癌细胞毒性及作用机制,以期进一步完善其药理机制。在Ⅰ/Ⅱa期临床研究,设计晚期NSCLC,息者,分75mgTID、100mg TID、125mg TID、150mg TID四组,口服盐酸埃克替尼片,连续28天,评估其安全性和耐受性,并进一步评估稳态下盐酸埃克替尼疗效。研究方法:细胞水平试验观察盐酸埃克替尼对表皮生长因子（Epidermal Growth Factor,EGF）刺激引起EGFR,磷酸化EGFR（p-EGFR）表达的影响;运用xCELLigence实时监测系统检测72H内的盐酸埃克替尼对不同的肺癌细胞株的生长曲线的影响及计算IC₅₀值。本Ⅰ/Ⅱa期研究属开放、单中心、剂量递增试验（中国临床试验注册中心注册号:ChiCTR-TNRC-00000194）。病人按用药剂量75mg每8小时1次（TID）、100mg TID、125mg TID、150mg TID分4组,每个剂量组保证完成6例,由低剂量到高剂量按固定剂量口服给药方案。根据限制性毒性剂量（Dose-LimitingToxicity,DLT）的发生情况确定最大耐受剂量（Maximum Tolerated Dose,MTD）。根据临床所观察到的安全性和有效性结果资料推荐Ⅱ/Ⅲ期临床试验拟用的单药给药方案。研究结果:在细胞试验水平,正常HCC827细胞中有低水平的p-EGFR表达,经EGF刺激,p-EGFR表达明显升高,在埃克替尼预处理后,可以抑制EGF诱导的p-EGFR高水平表达,且随着埃克替尼的增加,p-EGFR水平明显降低,呈良好的剂量依赖效应,吉非替尼预处理产生类似作用。而两药对EGFR的表达无明显影响。在细胞毒性试验中,PC-9细胞对盐酸埃克替尼,吉非替尼两种药物敏感性高,即使在1.25mol·L^-1浓度,细胞也基本死亡。HCC827次之,H1650不敏感,95-D,801-D对盐酸埃克替尼,吉非替尼两种药物完全不敏感。本次临床试验从2007年12月至2009年1月共入组33例晚期非小细胞患者,按照方案,分75mg TID（225mg/天）、100mg TID（300mg/天）、125mg TID（375mg/天）、150mg TID（450mg/天）四个剂量组进行剂量递增研究。原发肿瘤TNM临床分期除3例病人未进行详细分期或Ⅲa期,其余病人均为Ⅲb期及Ⅳ期病人。33例病人既往全部至少均有一个含铂类药物治疗方案的化疗史,5例病人既往有肿瘤放疗史,3例病人有肿瘤手术史。33例受试者按方案全部纳入安全分析,以分析安全性。33例中30例完成连续28天一个周期治疗,1例病人因疾病进展提前终止试验,1例病人因家属要求提前终止试验,1例病人因违反研究方案提前终止试验。本试验对32例病人进行了初步疗效评价。在盐酸埃克替尼治疗的28天中,四个剂量组最常见的不良反应为Ⅰ或Ⅱ度的皮疹45.5%（15/33）、Ⅰ或Ⅱ度的腹泻24.2%（8/33）、Ⅰ或Ⅱ度的白细胞下降12.2%（4/33）和Ⅰ-Ⅲ度的肝转氨酶升高12.2%（4/33）。在24周时四组的按RECIST标准评价的肿瘤总体反应率ORR（CR+PR）为21.9%（7/32）;疾病控制率DCR（CR+PR+SD）为43.8%（14/32）。研究结论:盐酸埃克替尼对EGF刺激引起的HCC827细胞中的EGFR磷酸化有抑制作用,且呈良好的剂量依赖关系;盐酸埃克替尼对不同的肺癌细胞敏感程度完全不同。在存在19外显子突变的细胞药物敏感性高,而对大细胞癌完全不敏感。在晚期非小细胞患者中,75mg TID（225mg/天）、100mg TID（300mg/天）、125mg TID（375mg/天）、150mg TID（450mg/天）四个剂量组均显示出良好的安全性和耐受性。本研究初步结果首次说明盐酸埃克替尼对于晚期非小细胞肺癌患者具有一定的疗效,但有待于Ⅱ/Ⅲ期临床试验中加以证实。125mg TID或150mg TID可以作为下阶段盐酸埃克替尼Ⅱ/Ⅲ期临床试验的治疗推荐剂量。更多还原

【Abstract】 Background and Objective:Targeted chemotherapies using epidermal growth factor receptor-tyrosine kinase inhibitor（EGFR-TKI） is now a well treatment for some kinds of malignancy.Gefitinib and erlotinib are approved for the treatment of patients with metastatic non-small-cell lung cancer（NSCLC）.However,only 9-26%of advanced-stage NSCLC patients could benefit from treatment with these agents in clinical trials.Icotinib hydrochloride （BPI-2009H）,a new selective EGFR-TKI has already demonstrated active and selective antitumor activities in both in vitro and in vivo preclinical studies.At the cellular level, the study design to assess pharmacological mechanism and cytotoxicity on several lung cancer cell lines.The phaseⅠ/Ⅱa trial design to assess the safety and tolerability of icotinib,and to explore clinical activity in patients with advanced NSCLC after failure of prior platinum-based chemotherapy.Methods:The evaluation of icotinib hydrochloride toxicity by a real-time cell electroni c sensing（RT-CES）,the EGFR,phosphorylated EGFR（p-EGFR） expression of e pidermal growth factor（EGF）-stimulated lung cancer cell line were measured by Western -blot analysis.A phaseⅠ/Ⅱa,open-label trial（Trial registration ID:ChiC TR-TNRC-00000194 at the Chinese Clinical Trial Register）.Oral icotinib（75,10 0,125,or 150 mg） was administered once 8 hours（TID） for 28-continuous day c ycle until disease progression or undue toxicity.Tumor response was assessed by RECIST.Patients continued treatment at the same dose level as long as icotinib was tolerated and there was no evidence of disease progression.Results:In control HCC827 cells the p-EGFR expression are low,after stimulated by EGF, EGFR expression increased markly.Icotinib hydrochloride pretreatment can inhibit EGF-induced highly p-EGFR expressed and showed a good dose-dependent effects. Gefitinib pretreatment produced a similar role.The two drugs on the expression of EGFR had no significant effect.In the cell toxicity test,PC-9 was sensitive to icotinib hydrochloride or gefitinib,even if the 1.25nM concentration,HCC827 also sensitive to both drugs.H1650 was insensitive.95-D,801-D were totally insensitive to both drugs.From Dec 19 2007,we started the trial.The last patient finished recruitment on the Jan 2nd 2009.33 patients were enrolled.The highest treatment-related adverse events （TRAEs） were acne-like（or folliculitis） rash（15/33,45.5%）,diarrhea（8/33, 24.2%）,,white blood cells decreased（4/33,12.2%） and hepatic transaminases elevated（4/33,12.2%）.They were mostly grade 1-2 and reversible on continuous treatment.No change in icotinib safety profile was observed with prolonged administration.None of these TRAEs were grade 4.Grade 3 TRAEs,which occurred in two patients,included hepatic transaminases elevated（one patients） at dose 100mg TID,mouth lceration（one patients） at dose 125mg TID.Maximum-tolerated dose（MTD） was not reached.32 patients were enrolled for clinical activity assess.No complete responses（CR） were observed.At the 24^th weeks,7 patients had PR,7 patients had SD, corresponding to a objective response rate（ORR） of 21.9%（7/32） and disease control rate（DCR） of 43.8%（14/32）.Conclusion:Icotinib hydrochloride can inhibit EGF-induced highly p-EGFR expressed in HCC827 cell line with good dose-dependent mananer.Different lung cancer cell lines are with different sensitivity to icotinib hydrochloride.In the presence of mutations in exon 19 of cell is with the high sensitivity to icotinib hydrochloride.Oral icotinib was generally well tolerated,with manageable and reversible AEs in patients with advanced NSCLC.Icotinib showed positive clinical anti-tumor activities in patients with advanced NSCLC.The recommended dose for phaseⅡ/Ⅲstudy with icotinib is 125mg or 150mg,TID.更多还原