Erlotinib may stop the growth of tumor cells by blocking the enzymes necessary for their
growth. Monoclonal antibodies, such as bevacizumab, can block tumor growth in different
ways. Some block the ability of tumor cells to grow and spread. Others find tumor cells and
help kill them or carry tumor-killing substances to them. Bevacizumab may also stop the
growth of colorectal cancer by blocking blood flow to the tumor. Drugs used in chemotherapy
work in different ways to stop tumor cells from dividing so they stop growing or die.
Combining erlotinib and bevacizumab with combination chemotherapy may kill more tumor cells.
This phase I trial is studying the side effects and best dose of erlotinib when given
together with bevacizumab, fluorouracil, leucovorin, and oxaliplatin in treating patients
with metastatic or locally advanced colorectal cancer.
I. To determine the maximum tolerated dose (MTD) of OSI-774 given in combination with FOLFOX
4 and Bevacizumab, in patients with advanced colorectal cancer.
II. To characterize the toxicity profile of this regimen. III. To explore the antitumor
activity of this combination.
I. To characterize the pharmacokinetics of OSI-774 given with FOLFOX 4, and Bevacizumab.
II. To determine the relationship between CYP3A4 activity and OSI-774 clearance.
III. To correlate Cytochrome P450 activity with OSI-774 PK using midazolam clearance.
IV. To determine the relationship between expression and activation of the EGFR and related
signaling pathways and outcome of patients with colorectal cancer patients who are treated
with OSI-774 in combination with FOLFOX 4 and Bevacizumab.
V. To explore the biological effects of OSI-774 in patients with advanced colorectal cancer
and its relationship with dose and plasma concentration.
VI. To explore the use of fluorodeoxy-glucose (FDG) positron emission tomography (PET) scan
to predict the biological effects and outcome of patients with colorectal cancer who are
treated with OSI-774 and FOLFOX 4 and Bevacizumab.
VII. To assess 5FU PK when given in this manner, and to correlate with several previously
characterized genetic polymorphisms and drug response VIII. To evaluate the association of
allelic variants in AAG and OSI-774 disposition.
OUTLINE: This is a dose-escalation study of erlotinib.
Patients receive oral elotinib alone once daily for 1 week before the beginning of course 1.
Patients then receive oral erlotinib once daily on days 1-28; oxaliplatin IV over 2 hours on
day 1; and leucovorin calcium IV over 2 hours and fluorouracil IV over 22 hours on days 1
and 2. Patients also receive bevacizumab IV over 30-90 minutes on day 15 of course 1 and on
days 1 and 15 of all subsequent courses. Courses repeat every 28 days in the absence of
disease progression or unacceptable toxicity.
Cohorts of 3-6 patients receive escalating doses of erlotinib until the maximum tolerated
dose (MTD) is determined. The MTD is defined as the dose at which no more than 2 of 6
patients experience dose-limiting toxicity.
PROJECTED ACCRUAL: Approximately 38 patients will be accrued for this study within 19-38
- Histologically or cytologically confirmed diagnosis of colorectal adenocarcinoma with
metastatic or locally advanced disease not amenable to curative therapy
- The patients may have therapy for advanced disease completed no less than 28 days
prior to enrolling on this protocol; chemotherapy in the adjuvant setting may be
allowed, but must have been completed at least 120 days prior to enrollment onto this
protocol; prior bevacizumab is allowed
- ECOG performance status =< 1 (Karnofsky >= 60%)
- Life expectancy of greater than 12 weeks
- Leukocytes >= 3,000/ul
- Absolute neutrophil count >= 1,500/ul
- Platelets >= 100,000/ul
- Total bilirubin =< 2 mg/dL
- AST(SGOT)/ALT(SGPT) =< 2.5 X institutional upper limit of normal (=< 5 X
institutional upper limit of normal for patients with liver metastatsis)
- Creatinine =< 1.5 mg/dL OR creatinine clearance >= 60 mL/min/1.73 m^2 for patients
with creatinine levels above institutional normal
- In addition, those patients consenting to have a tumor biopsy and enrolling on that
portion of the protocol must have:
- PTT < 40 seconds
- PT < 2 seconds more than ULN
- Patients must have unidimensionally-measurable disease, defined as at least one
lesion that can be accurately measured in at least one dimension (longest diameter to
be recorded) as >= 20 mm with conventional techniques or as >= 10 mm with spiral CT
- Ability to understand and the willingness to sign a written informed consent document
- After the MTD has been defined and 10-20 patients have been treated at this dose
level, enrollment will be restricted to patients who have tumor lesions amenable to
sequential sampling, if less than 10 patients have had this performed
- Patients undergoing tumor biopsies must not be taking any anti-platelet agents or
anticoagulants for at least 5 days prior to biopsy; tumor that will be considered for
biopsy will include skin lesions, liver metastases, and peripheral lymph nodes
(excluding supraclavicular and high cervical nodes), but will not include lung
nodules; if a liver biopsy is being performed, the patient's films (CT or MRI) must
be reviewed by the radiologist performing the biopsy (Dr Macura), who must feel that
a biopsy is safe and carry minimal risk
- No concurrent nephritic syndrome, uncontrolled hypertension, congestive heart failure
- Previous oxaliplatin therapy for metastatic disease; (prior adjuvant therapy with
oxaliplatin is allowed as long as 120 days have elapsed since the last oxaliplatin
- Less than 120 days elapsed time between chemotherapy treatment for adjuvant disease
and enrollment onto this protocol or less than 28 days between therapy for metastatic
disease and enrollment onto this protocol
- Patients with known brain metastases should be excluded from this clinical trial
because of their poor prognosis and because they often develop progressive neurologic
dysfunction that would confound the evaluation of neurologic and other adverse events
- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to OSI-774, oxaliplatin, 5-FU, or leucovorin
- Patients with a significant neuropathy (greater than grade 2) not controlled despite
- Prior treatment with EGFR targeting therapies
- Major surgery or significant traumatic injury occurring within 28 days prior to
treatment; all surgical wounds must be healed
- Abnormalities of the cornea based on history (e.g., dry eye syndrome, Sjogren's
syndrome), congenital abnormality (e.g., Fuch's dystrophy), abnormal slit-lamp
examination using a vital dye (e.g., fluorescein, Bengal Rose), and/or an abnormal
corneal sensitivity test (Schirmer test or similar tear production test)
- Gastrointestinal tract disease resulting in an inability to take oral medication or a
requirement for IV alimentation, prior surgical procedures affecting absorption, or
active peptic ulcer disease
- Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance with
- Pregnant women are excluded from this study because OSI-774 is an epidermal growth
factor inhibitor with the potential for teratogenic or abortifacient effects based on
the data suggesting that EGFR expression is important for normal organ development;
because there is an unknown but potential risk for adverse events in nursing infants
secondary to treatment of the mother with OSI-774, breastfeeding should be
discontinued if the mother is treated with OSI-774; because patients with immune
deficiency are at increased risk of lethal infections when treated with
marrow-suppressive therapy, HIV-positive patients receiving combination
anti-retroviral therapy are excluded from the study because of possible
pharmacokinetic interactions with OSI-774; appropriate studies will be undertaken in
patients receiving combination anti-retroviral therapy when indicated
- Patients with only non-measurable disease, defined as all other lesions, including
small lesions (longest diameter < 20 mm with conventional techniques or <10 mm with
spiral CT scan) and truly non-measurable lesions, which include the following:
- Bone lesions;
- Leptomeningeal disease;
- Pleural/pericardial effusion;
- Inflammatory breast disease;
- Lymphangitis cutis/pulmonis;
- Abdominal masses that are not confirmed and followed by imaging techniques;
- Cystic lesions
- Patients without sufficient central venous access for therapy
- Patients with thromboembolic events (MI, TIA, stroke, or angina) occurring within the
past 6 months prior to the start of therapy