title: Combination targeted therapy with sorafenib and bevacizumab results in enhanced toxicity and antitumor activity.
abstract: OBJECTIVE
  Sorafenib inhibits Raf kinase and vascular endothelial growth factor (VEGF) receptor. Bevacizumab is a monoclonal antibody targeted against VEGF. We hypothesized that the complementary inhibition of VEGF signaling would have synergistic therapeutic effects.
  
  
  METHODS
  Patients had advanced solid tumors, Eastern Cooperative Oncology Group performance status of 0 to 1, and good end-organ function. A phase I dose-escalation trial of sorafenib and bevacizumab was initiated at below-recommended single-agent doses because of possible overlapping toxicity: sorafenib 200 mg orally twice daily and bevacizumab intravenously at 5 mg/kg (dose level [DL] 1) or 10 mg/kg (DL2) every 2 weeks. Additional patients were enrolled at the maximum-tolerated dose (MTD).
  
  
  RESULTS
  Thirty-nine patients were treated. DL1 was the MTD and administered in cohort 2 (N = 27). Dose-limiting toxicity in DL2 was grade 3 proteinuria and thrombocytopenia. Adverse events included hypertension, hand-foot syndrome, diarrhea, transaminitis, and fatigue. Partial responses (PRs) were seen in six (43%) of 13 patients with ovarian cancer (response duration range, 4 to 22+ months) and one of three patients with renal cell cancer (response duration, 14 months). PR or disease stabilization >or= 4 months (median, 6 months; range, 4 to 22+ months) was seen in 22 (59%) of 37 assessable patients. The majority (74%) required sorafenib dose reduction to 200 mg/d at a median of four cycles (range, one to 12 cycles).
  
  
  CONCLUSIONS
  Combination therapy with sorafenib and bevacizumab has promising clinical activity, especially in patients with ovarian cancer. The rapidity and frequency of sorafenib dose reductions indicates that sorafenib at 200 mg twice daily with bevacizumab 5 mg/kg every 2 weeks may not be tolerable long term, and alternate sorafenib dosing schedules should be explored.
authors.affiliation: Medical Oncology Branch, Biostatistics and Data Management Section, and Genetics Branch, Center for Cancer Research, National Institutes of Health, Bethesda, MD, USA.
authors.forename: Nilofer S
authors.initials: NS
authors.lastname: Azad
authors.forename: Edwin M
authors.initials: EM
authors.lastname: Posadas
authors.forename: Virginia E
authors.initials: VE
authors.lastname: Kwitkowski
authors.forename: Seth M
authors.initials: SM
authors.lastname: Steinberg
authors.forename: Lokesh
authors.initials: L
authors.lastname: Jain
authors.forename: Christina M
authors.initials: CM
authors.lastname: Annunziata
authors.forename: Lori
authors.initials: L
authors.lastname: Minasian
authors.forename: Gisele
authors.initials: G
authors.lastname: Sarosy
authors.forename: Herbert L
authors.initials: HL
authors.lastname: Kotz
authors.forename: Ahalya
authors.initials: A
authors.lastname: Premkumar
authors.forename: Liang
authors.initials: L
authors.lastname: Cao
authors.forename: Deborah
authors.initials: D
authors.lastname: McNally
authors.forename: Catherine
authors.initials: C
authors.lastname: Chow
authors.forename: Helen X
authors.initials: HX
authors.lastname: Chen
authors.forename: John J
authors.initials: JJ
authors.lastname: Wright
authors.forename: William D
authors.initials: WD
authors.lastname: Figg
authors.forename: Elise C
authors.initials: EC
authors.lastname: Kohn
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000368:Aged; D020533:Angiogenesis Inhibitors / Q000008:administration & dosage; D000911:Antibodies, Monoclonal / Q000008:administration & dosage; D061067:Antibodies, Monoclonal, Humanized; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use*; D001557:Benzenesulfonates / Q000008:administration & dosage; D000068258:Bevacizumab; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D008297:Male; D020714:Maximum Tolerated Dose; D008875:Middle Aged; D009367:Neoplasm Staging; D009369:Neoplasms / Q000188:drug therapy* / Q000201:enzymology / Q000473:pathology; D009536:Niacinamide / Q000031:analogs & derivatives; D010051:Ovarian Neoplasms / Q000188:drug therapy; D010671:Phenylurea Compounds; D047428:Protein Kinase Inhibitors / Q000008:administration & dosage; D011725:Pyridines / Q000008:administration & dosage; D040262:Receptors, Vascular Endothelial Growth Factor / Q000037:antagonists & inhibitors; D000077157:Sorafenib; D016896:Treatment Outcome; D042461:Vascular Endothelial Growth Factor A / Q000037:antagonists & inhibitors / Q000097:blood; D048490:raf Kinases / Q000037:antagonists & inhibitors
chemical_list: D020533:Angiogenesis Inhibitors; D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D001557:Benzenesulfonates; D010671:Phenylurea Compounds; D047428:Protein Kinase Inhibitors; D011725:Pyridines; C467484:VEGFA protein, human; D042461:Vascular Endothelial Growth Factor A; D009536:Niacinamide; D000068258:Bevacizumab; D000077157:Sorafenib; D040262:Receptors, Vascular Endothelial Growth Factor; D048490:raf Kinases