Article
作者: de Marinis, Filippo ; Olevsky, Olga ; Sheaff, Michael ; Grosso, Federica ; Nolan, Luke ; MacKean, Melanie ; Szlosarek, Peter W. ; Tsao, Anne ; Srivastav, Ratnesh ; Roy, Amy ; Steele, Jeremy ; Wang, Chin-Chou ; Karapetis, Christos ; Zauderer, Marjorie G. ; O’Byrne, Kenneth J. ; Stella, Maria Giulia ; Gilligan, David ; Shaw, Paul ; Chong, Inn-Wen ; Bomalaski, John ; Johnston, Amanda ; Kindler, Hedy ; Papadatos-Pastos, Dionysis ; Franks, Kevin ; Taylor, Paul ; Ceresoli, Giovanni L. ; Lind, Michael J. ; Fennell, Dean A. ; Zilembo, Nicoletta ; Steele, Nicola ; Cortinovis, Diego ; Kuo, Chih-Ling ; John, Thomas ; Creelan, Benjamin C. ; Rolfo, Christian D. ; Mansfield, Aaron S. ; Shiu, Chiung-Fang ; Sarkodie, Thomas ; Chitnis, Meenali ; Upadhyay, Sunil ; Mencoboni, Manlio ; Chella, Antonio ; Rybkin, Igor I. ; Nowak, Anna K.
Importance:Arginine deprivation using ADI-PEG20 (pegargiminase) combined with chemotherapy is untested in a randomized study among patients with cancer. ATOMIC-Meso (ADI-PEG20 Targeting of Malignancies Induces Cytotoxicity-Mesothelioma) is a pivotal trial comparing standard first-line chemotherapy plus pegargiminase or placebo in patients with nonepithelioid pleural mesothelioma.
Objective:To determine the effect of pegargiminase-based chemotherapy on survival in nonepithelioid pleural mesothelioma, an arginine-auxotrophic tumor.
Design, Setting, and Participants:This was a phase 2-3, double-blind randomized clinical trial conducted at 43 centers in 5 countries that included patients with chemotherapy-naive nonepithelioid pleural mesothelioma from August 1, 2017, to August 15, 2021, with at least 12 months’ follow-up. Final follow-up was on August 15, 2022. Data analysis was performed from March 2018 to June 2023.
Intervention:Patients were randomly assigned (1:1) to receive weekly intramuscular pegargiminase (36.8 mg/m2) or placebo. All patients received intravenous pemetrexed (500 mg/m2) and platinum (75-mg/m2 cisplatin or carboplatin area under the curve 5) chemotherapy every 3 weeks up to 6 cycles. Pegargiminase or placebo was continued until progression, toxicity, or 24 months.
Main Outcomes and Measures:The primary end point was overall survival, and secondary end points were progression-free survival and safety. Response rate by blinded independent central review was assessed in the phase 2 portion only.
Results:Among 249 randomized patients (mean [SD] age, 69.5 [7.9] years; 43 female individuals [17.3%] and 206 male individuals [82.7%]), all were included in the analysis. The median overall survival was 9.3 months (95% CI, 7.9-11.8 months) with pegargiminase-chemotherapy as compared with 7.7 months (95% CI, 6.1-9.5 months) with placebo-chemotherapy (hazard ratio [HR] for death, 0.71; 95% CI, 0.55-0.93; P = .02). The median progression-free survival was 6.2 months (95% CI, 5.8-7.4 months) with pegargiminase-chemotherapy as compared with 5.6 months (95% CI, 4.1-5.9 months) with placebo-chemotherapy (HR, 0.65; 95% CI, 0.46-0.90; P = .02). Grade 3 to 4 adverse events with pegargiminase occurred in 36 patients (28.8%) and with placebo in 21 patients (16.9%); drug hypersensitivity and skin reactions occurred in the experimental arm in 3 patients (2.4%) and 2 patients (1.6%), respectively, and none in the placebo arm. Rates of poststudy treatments were comparable in both arms (57 patients [45.6%] with pegargiminase vs 58 patients [46.8%] with placebo).
Conclusions and Relevance:In this randomized clinical trial of arginine depletion with pegargiminase plus chemotherapy, survival was extended beyond standard chemotherapy with a favorable safety profile in patients with nonepithelioid pleural mesothelioma. Pegargiminase-based chemotherapy as a novel antimetabolite strategy for mesothelioma validates wider clinical testing in oncology.
Trial Registration:ClinicalTrials.gov Identifier: NCT02709512