RATIONALE: Drugs used in chemotherapy, such as hydroxychloroquine and temozolomide, work in
different ways to stop the growth of tumor cells, either by killing the cells or by stopping
them from dividing. Giving more than one drug (combination chemotherapy) may kill more tumor
PURPOSE: This phase I trial is studying the side effects and best dose of hydroxychloroquine
when given together with temozolomide in treating patients with metastatic or unresectable
- To determine the maximum tolerated dose (MTD) of hydroxychloroquine (HCQ) when
administered in combination with temozolomide (TMZ) in patients with metastatic or
unresectable solid tumors.
- To determine the toxicity and toxicity rate of HCQ when administered at the MTD in
combination with TMZ in these patients.
- To construct a population pharmacokinetic (PK) model using a limited sampling of whole
blood to determine the drug exposure of HCQ and HCQ metabolites in these patients.
- To measure changes in autophagic vesicle accumulation by immunoblotting against the
autophagy marker LC3 in protein lysates prepared from peripheral blood mononuclear
cells (PBMC) collected from patients treated with HCQ and TMZ.
- To measure changes in median number of autophagic vesicles by electron microscopy in
PBMC collected from patients treated with HCQ and TMZ.
- To assess tumor changes in LC3 and caspase 3 cleavage by western blotting.
- To assess tumor cell death characteristics by immunohistochemical methods (Ki67, TUNEL
staining, cleaved caspase 3).
- To evaluate autophagy by electron microscopy.
- To define associations between changes in LC3 levels from baseline in PBMC with HCQ
- To measure the levels of HMGB1 in the serum of patients treated with HCQ and TMZ.
OUTLINE: This is a dose-escalation study of hydroxychloroquine (HCQ).
Patients receive oral HCQ alone once or twice daily for 14 days. Patients then receive oral
HCQ once or twice daily on days 1-28 and oral temozolomide once daily on days 1-7 and 15-21.
Treatment with HCQ and temozolomide repeats every 28 days in the absence of disease
progression or unacceptable toxicity.
Patients undergo blood sample collection periodically for pharmacodynamic and
pharmacokinetic correlative studies. Autophagic vesicles in blood samples are quantified by
immunoblotting against the autophagy protein LC3 and by electron microscopy.
Pharmacokinetics are analyzed by high-performance liquid chromatography with tandem mass
spectrometry. Patients with tumors amenable to biopsy also undergo serial biopsies. Tumor
tissue samples are assessed for tumor cell apoptosis and proliferation using Ki67 and TUNEL
staining and for the number of autophagic vesicles and nuclear changes characteristic of
apoptotic, autophagic, or necrotic cell death by western blotting and electron microscopy.
After completion of study treatment, patients are followed periodically.
- Histologically or cytologically confirmed solid tumor
- Metastatic or unresectable disease
- Refractory to standard therapy or no standard therapy exists
- Measurable disease by RECIST criteria
- Brain metastases allowed provided patient completed radiotherapy (if radiotherapy was
clinically indicated at the time of diagnosis) AND discontinued steroids prior to
- ECOG performance status 0-1
- WBC ≥ 3,000/mm³
- Absolute granulocyte count ≥ 1,500/mm³
- Platelet count ≥ 100,000/mm³
- Serum creatinine ≤ 2.0 times upper limit of normal (ULN)
- Total bilirubin ≤ 1.5 times ULN (< 3.0 times ULN in the presence of Gilbert's
- AST and ALT ≤ 2.5 times ULN (≤ 5.0 times ULN in the presence of liver metastases)
- aPTT normal
- INR ≤ 1.5 (if on anticoagulation, INR must be < 1.5 prior to starting
- Not pregnant or nursing
- Negative pregnancy test
- Fertile patients must use effective contraception
- HIV negative
- No porphyria
- No psoriasis, unless the disease is well controlled and patient is under the care of
a specialist who agrees to monitor the patient for exacerbations
- No previously documented macular degeneration or diabetic retinopathy
- No concurrent serious illness including, but not limited to, any of the following:
- Ongoing or active infection requiring parenteral antibiotics
- Clinically significant cardiovascular disease (e.g., uncontrolled hypertension,
myocardial infarction, or unstable angina)
- New York Heart Association class II-IV congestive heart failure
- Serious cardiac arrhythmia requiring medication
- Peripheral vascular disease ≥ grade 2 within the past year
- Psychiatric illness/social situation that would limit compliance with study
- No other concurrent malignancies, other than basal cell skin cancer, squamous cell
skin cancer, carcinoma in situ of the cervix, or ductal or lobular carcinoma in situ
of the breast
PRIOR CONCURRENT THERAPY:
- See Disease Characteristics
- Recovered from all prior therapy
- The following prior therapy is allowed in the adjuvant or metastatic disease setting:
- Immunotherapy (interferon, aldesleukin, or sargramostim [GM-CSF])
- Chemotherapy, either as a single-agent or as combination therapy
- Vaccine therapy
- Targeted or biological therapy
- Chloroquine derivatives
- At least 4 weeks since prior active immunotherapy (aldesleukin, interferon, or
- At least 4 weeks since prior chemotherapy
- At least 2 weeks since prior oral targeted therapies
- More than 4 weeks since prior and no other concurrent investigational anticancer
therapy (except for vaccines)
- No prior temozolomide
- Prior radiotherapy allowed
- If radiotherapy has been administered to a lesion, there must be radiographic
evidence of progression of that lesion in order for that lesion to constitute
measurable disease or to be included in the measured target lesions
- No concurrent cytochrome P450 enzyme-inducing antiepileptic drugs (phenytoin,
carbamazepine, phenobarbital, primidone, or oxcarbazepine), rifampin, or Hypericum
perforatum (St. John's wort)
- No other concurrent anticancer therapy