Clinical trial NCT00950365
Conditions: Bronchioloalveolar Carcinoma Large Cell Lung Carcinoma Lung Adenocarcinoma Recurrent Non-Small Cell Lung Carcinoma Stage IIIB Non-Small Cell Lung Cancer Stage IV Non-Small Cell Lung Cancer
Sponsor: Albert Einstein College of Medicine
Start date: 2006-04-01; Completion date: 2017-11-17
Enrollment: 79 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This randomized phase II trial studies how well pemetrexed disodium with or without erlotinib hydrochloride works in treating patients with stage IIIB-IV or recurrent non-small cell lung cancer. Drugs used in chemotherapy, such as pemetrexed disodium, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Erlotinib hydrochloride may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. It is not yet known whether pemetrexed disodium is more effective with or without erlotinib hydrochloride in treating non-small cell lung cancer.

Detailed description:
PRIMARY OBJECTIVES:

I. To evaluate progression free survival (PFS) in the schedule-modulated concomitant administration of erlotinib (erlotinib hydrochloride) and pemetrexed (pemetrexed disodium), and in single agent pemetrexed in patients with advanced non-small cell lung cancer (NSCLC) as second-line chemotherapy.

SECONDARY OBJECTIVES:

I. To evaluate antitumor objective response rate (complete response \[CR\] + partial response \[PR\]) per Response Evaluation Criteria in Solid Tumors (RECIST) criteria.

II. To evaluate disease control rate (response rate + stable disease, i.e., CR+PR+ stable disease \[SD\]) and duration of response.

III. To evaluate median time to progression (TTP) and overall survival (OS). IV. To evaluate the safety profile of concurrent pemetrexed and erlotinib versus single agent pemetrexed.

TERTIARY OBJECTIVES:

i. To determine several molecular and cellular biomarkers in the tumors, the skin and the serum that are predictive of the efficacy of pemetrexed and erlotinib.

OUTLINE: Patients are randomized to 1 of 2 treatment arms.

ARM A: Patients receive pemetrexed disodium intravenously (IV) over 10 minutes on day 1. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.

ARM B: Patients receive pemetrexed disodium IV as in Arm A and erlotinib hydrochloride orally (PO) once daily (QD) on days 2-17. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up for 12 months.

Arms: arm 1: Patients receive pemetrexed disodium IV over 10 minutes on day 1. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity. arm 2: Patients receive pemetrexed disodium IV as in Arm A and erlotinib hydrochloride PO QD on days 2-17. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.
Interventions: intervention 1: Erlotinib Hydrochloride intervention 2: Laboratory Biomarker Analysis intervention 3: Pemetrexed Disodium
Intervention descriptions: intervention 1: Given PO intervention 2: Correlative studies intervention 3: Given IV

Protocol documents:
Prot_SAP_000.pdf: 
 
i
MMC IRB Protocol #: 05-10-277 
Version: 1.1, Date: 8/15/2005 
Version: 1.2, Date: 11/4/2005 
Amendment 1: 1/05/2006 
Amendment 2: 2/15/2006 
Amendment 3: 6/12/2006 
Amendment 4: 6/10/2007 
Amendment 5: 2/2/2008 
Amendment 6: 12/8/2008 
Amendment 7: 2/23/2009 
Amendment 8: 04/18/2011 
 
 
TITLE:  A Randomized Phase II Study of Schedule-Modulated Concomitant  
Pemetrexed (Alimta) and Erlotinib (Tarceva) vs Single Agent Pemetrexed (Alimta®)  
in Patients with Progressive or Recurrent Non-Small Cell Lung Cancer (NSCLC)  
 
 
 
 
 
 
Principal-Investigator: 
Roman Perez-Soler, M.D.  
 
 
 
 
Montefiore Medical Center 
 
 
 
 
Department of Oncology, Hofheimer 100 
 
 
 
 
111 East 210th Street 
 
 
 
 
Bronx, NY 10467-2490 
 
 
 
 
Phone: 718-920-4826/Fax: 718-798-7474 
 
 
 
Email: rperezso@montefiore.org 
 
Overall Principal-Investigator: 
Tianhong Li, MD PhD 
 
 
 
 
UC Davis Cancer Center 
 
 
  
Hematology/Oncology 
 
 
 
4501 X Street, Suite 3016 
 
 
 
Sacramento, CA 95817 
 
 
 
Phone: (916) 734-3771 
 
 
 
Fax:  (916) 734-7946  
 
 
Co-Investigators: 
 
David R. Gandara, MD 
 
 
Bilal Piperdi, MD; William V. Walsh, MD 
UC Davis Cancer Center 
 
 
University of Massachusetts-Memorial Campus  
Hematology/Oncology 
 
 
Hematology/Oncology 
4501 X Street, Suite 3016 
 
 
55 Lake Avenue N. 
Sacramento, CA 95817 
 
 
Worcester, MA 01655 
Phone: (916) 734-3771 
 
 
Phone: (508) 856-3702 
Fax:  (916) 734-7946  
 
 
Fax: (508) 856-6715 
Email: david.gandara@ucdmc.udavis.edu 
Email: piperdib@ummhc.org;  
 


 
ii
Rasim Gucalp, M.D.   
 
 
 
Missak Haigentz, M.D.  
Montefiore Medical Center-Moses Division  
Montefiore Medical Center 
Department of Oncology, Hofheimer 100 
 
Department of Oncology, Hofheimer 100 
111 East 210th Street  
 
 
 
111 East 210th Street 
Bronx, NY 10467-2490 
 
 
 
Bronx, NY 10467-2490 
 
 
 
Phone: 718-920-4826/Fax: 718-798-7474 
 
Phone: 718-920-4826/Fax: 718-798-7474 
 
Email: rgucalp@montefiore.org 
 
 
Email: mhaigent@montefiore.org 
 
 
 
 
Fernando J. Camacho, M.D.  
 
 
Fabio Volterra, M.D.  
Mark A. Ramirez, M.D. 
 
 
 
Anthony Hoffman, M.D. 
Daniel Friedman, M.D 
 
 
 
Avi Retter, M.D. 
Bronx River Medical Associates, P.C. 
 
Eastchester Center for Cancer Care 
60 East 208th Street  
 
 
 
2330 Eastchester Road 
Bronx, N.Y. 10467 
 
 
 
 
Bronx, NY 10469 
Phone: 718- 405-1700/Fax: 718-405-7231 
 
Phone: 718-732-4000/ Fax: 718-881-3036 
 
 
Steven Keller, M.D.   
 
 
 
David Lee, M.D. 
Chief, Cardiothoracic Surgery 
 
 
Department of Surgery 
Montefiore Medical Center 
 
 
 
Montefiore Medical Center 
111 East 210th Street  
 
 
 
1575 Blondell Avenue 
Bronx, NY 10467-2490 
 
 
 
Bronx, NY 10461 
Phone: 718-920-7580/Fax: 718-652-4517 
 
Phone: 718-405-8238/Fax: 718-405-8292 
Email: skeller@montefiore.org 
 
 
Email: dlee@montefiore.org 
 
 
Andrew Berman, M.D.  
 
 
 
Jay Dobkin, M.D. 
 
 
 
Montefiore Medical Center 
 
 
 
Montefiore Medical Center 
Department of Medicine-Pulmonary   
 
Department of Medicine-Pulmonary 
1825 Eastchester Road 
 
 
 
1825 Eastchester Road 
Bronx, NY 10461 
 
 
 
 
Bronx, NY 10461 
Phone: 718-904-2983/Fax: 718-904-2163 
 
Phone: 718-904-2983/Fax: 718-904-2163 
Email: aberman@montefiore.org  
 
 
Email: jdobkin@montefiore.org 
 
 
Maomi Li, M.D. Ph.D. 
 
 
 
Kathleen Whitney, M.D. 
Montefiore Medical Center 
 
 
 
Montefiore Medical Center 
Department of Pathology, Moses Division 
 
Department of Pathology, Einstein Division 
111 East 210th Street  
 
 
 
1825 Eastchester Road 
Bronx, NY 10467-2490 
 
 
 
Bronx, New York 10461 
Phone: 718-920-8152/Fax: 718-920-7611 
 
Phone: 718-904-2947/Fax: 718-904-2355 
Email: mli@montefiore.org   
 
 
Email: kwhitney@montefiore.org 


 
iii 
Statistician:  
 
Mimi Kim, PhD 
 
 
 
 
Albert Einstein College of Medicine 
 
 
 
1300 Morris Park Avenue, Belfer 1312C 
 
 
 
Bronx, New York 10461 
 
 
 
Phone: 718-430-3575/Fax: 718-430-8780 
 
 
 
Email: mikim@aecom.yu.edu 
 
 
Research Coordinators: 
 
 
Amy Paige 
 
 
 
                
   Srikanth Gajavelli 
Montefiore Medical Center-Weiler Division  
   Montefiore Medical Center 
Department of Oncology, First Floor  
 
   Department of Oncology 
1695 Eastchester Road 
 
 
 
   111 East 210th Street 
Bronx, New York 10461 
 
 
 
   Bronx, NY 10467 
Phone: 718-405-8539/Fax: 718-405-8526 
 
   Phone : 718-920-6193/Fax : 718-405-7412 
Email: apaige@montefiore.org                                  Email : sgajavel@montefiore.org  
 
Kimcita Vargas-Walker 
Central Protocol Office & Data Management Unit Coordinator 
Montefiore-Einstein Cancer Center 
Montefiore Medical Center-Weiler Division 
1825 Eastchester Road 
2 South Room 59 
Bronx, NY 10461 
Phone: 718-904-2503/Fax: 718-822-0335 
Email: kvargasw@montefiore.org  
 
Research Nurses:  
 
 
 
Cheryl Baker  
 
 
 
 
Yoko Eng, RN 
Montefiore Medical Center-Weiler Division  
Montefiore Medical Center-Moses Division 
Department of Oncology, First Floor  
 
Department of Oncology, Gold Zone 
1695 Eastchester Road 
 
 
 
111 E. 210th Street 
Bronx, New York 10461 
 
 
 
Bronx, New York 10467 
Phone: 718-405-8508/Fax: 718-405-8526 
 
Phone:718-920-2090/Fax:718-405-7412 
Email: cbaker@montefiore.org 
 
 
Email: yeng@montefiore.org 
 
Study Agents and Their Suppliers:  
 
1. Pemetrexed Disodium (Alimta; LY231514), NSC # 698037, N021462, Eli Lilly. FDA 
approval date: 04-Feb-04. Pemetrexed will be provided by Eli Lilly free of charge. 
 
2. Erlotinib Hydrochloride (OSI-774; Tarceva), NSC # 718781, IND# 63383, N021743, OSI 
Pharmaceuticals/Genentech BioOncology.  FDA approval date: 18-Nov-04. Erlotinib will be 
provided by OSI Pharmaceuticals free of charge. 
 


 
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TABLE OF CONTENTS 
Page 
SCHEMA ...................................................................................................................................... vi 
 
1. OBJECTIVES ..........................................................................................................................1 
 
1.1  
Primary Objective 
…………………………………………………………………1 
 
1.2  
Secondary Objective …………………………………………………………………1 
 
1.3 
Correlatives Studies .....................................................................................................1 
 
2. BACKGROUND ......................................................................................................................1 
2.1 
Treatment for Advanced NSCLC...............................................................................1 
2.2 
Pemetrexed for Advanced NSCLC.............................................................................2 
2.3 
EGFR Signaling Pathway and Erlotinib for Advanced NSCLC .............................3 
2.4 
Rationale for the Proposed Study ...............................................................................6 
2.5 
Rationale for Correlative Studies ...............................................................................8 
 
2.6      Summary and Clinical Significance ..........................................................................11 
 
3. PATIENT SELECTION .......................................................................................................11 
3.1 
Eligibility Criteria  .....................................................................................................11 
3.2 
Exclusion Criteria ......................................................................................................13 
3.3 
Inclusion of Women and Minorities .........................................................................14 
3.4 
Registration of Patients .............................................................................................14 
 
4. TREATMENT PLAN ............................................................................................................14 
4.1  
Agent Administration ................................................................................................14 
 
Arm A: Control Arm .................................................................................................14 
 
Arm B: Concomitant Arm ........................................................................................15 
4.2  
Supportive Care Guidelines ......................................................................................15 
4.3  
Duration of Therapy ..................................................................................................16 
4.4 
After Protocol Therapy Pemetrexed ........................................................................16 
 
 
5. DOSING DELAYS/DOSE MODIFICATIONS ..................................................................17 
 
5.1  
General ........................................................................................................................17 
 
5.2  
Pemetrexed .................................................................................................................17 
5.3 
Erlotinib ......................................................................................................................18 
5.3.1 Dose Modification ......................................................................................................20 
5.3.2    Toxicity Management ................................................................................................20 
 
6. PHARMACEUTICAL INFORMATION ............................................................................20 
6.1  
Pemetrexed .................................................................................................................20 
6.2  
Erlotinib ......................................................................................................................27 
 
7. CORRELATIVE/SPECIAL STUDIES ...............................................................................30 
7.1  
Statement of Hypotheses and Objectives .................................................................30 
7.2  
Background and Rationale ........................................................................................31 
7.3  
Tissue Requirements and Assays ..............................................................................31 
 
 
Schema of Skin Biopsies ............................................................................................32 
 
 
Schema of Tumor Biopsies ........................................................................................33 
7.4  
Statistical Analysis  ....................................................................................................35 
7.5  
Submission of Samples ...............................................................................................35 


 
v
 
8. STUDY CALENDAR ............................................................................................................36 
 
9. MEASUREMENT OF EFFECT ..........................................................................................37 
9.1  
Definitions ...................................................................................................................37 
9.2  
Guidelines for Evaluation of Measurable Disease ..................................................38 
9.3  
Response Criteria .......................................................................................................38 
9.4  
Confirmatory Measurement/Duration of Response ...............................................40 
9.5  
Progression-Free Survival .........................................................................................41 
9.6  
Response Review ........................................................................................................41 
 
10. REGULATORY AND REPORTING REQUIREMENTS ................................................41 
10.1 
Expedited Adverse Event Reporting ........................................................................41 
10.2 
Reporting Serious Adverse Events Associated with Pemetrexed (Alimta®) 
…………………………………………………………………………………..……42 
10.3   Reporting Serious Adverse Events Associated with Erlotinib (Tarceva®) 
…………………………………………………………………………………..……42 
10.4   Reporting of Regulatory Documents………………………………………………42 
 
11. STATISTICAL CONSIDERATIONS .................................................................................42 
11.1 
Study Design/Analytic Plan .......................................................................................42 
11.2 
Sample Size/Accrual Rate .........................................................................................43 
11.3 
Randomization and Stratification ............................................................................44 
11.4 
Analyses for Correlative Studies ..............................................................................44 
11.5 
Reporting and Exclusions ..........................................................................................44 
 
12. REFERENCES ................................................................................................................. 45-50 
 
APPENDICES 
APPENDIX A 
Informed Consent Template.............................................................................................. A1-12 
APPENDIX B 
Performance Status Criteria ...................................................................................................B-1 
APPENDIX C 
NCI CTC (Common Toxicity Criteria) v3.0 ..........................................................................C-1 
APPENDIX D 
Correlative Studies: Paraffin-Embedded Tumor Samples .................................................... D-1 
APPENDIX E 
Correlative Studies:  Fresh Tissue Samples ........................................................................ E 1-2 
APPENDIX F 
Eligibility Checklist/Registration .......................................................................................  F 1-2 
APPENDIX G 
Erlotinib Incompatibilities ................................................................................................. G 1-2 
APPENDIX H 
Erlotinib Pill Diary ................................................................................................................ H-1 
APPENDIX I 
Smoking Status Questionnaire ................................................................................................ I-1 
APPENDIX J 
An Extension Study of Single Agent Erlotinib for Patients in Arm A ...................... ……..J 1-4 


 
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SCHEMA 
 
A Randomized Phase II Study of Schedule-Modulated Concomitant Pemetrexed (Alimta®) 
and Erlotinib (Tarceva®) versus Single Agent Pemetrexed (Alimta®) in Patients with  
Progressive or Recurrent Non-Small Cell Lung Cancer (NSCLC)  
 
 
21
Stratify:
Gender (female versus male)
ECOG PS (0/1 versus 2)
Prior smoking (≤15 PY versus >15 PY)
1:2 Randomization
Until disease progression, 
unacceptable toxicity or death
Arm A (Control Arm)
Alimta IV day 1, q3wk
Arm B (Experimental Arm)
Alimta IV day 1 +
Tarceva oral days 2-17, 
q3wk
Second-line Treatment for 
Progressive or Recurrent 
Advanced NSCLC
Until disease progression or 
unacceptable toxicity
PY, Pack Years
 
 
Planned Sample Size: 75 evaluable patients (25 for Arm A and 50 for Arm B); total of 82 
patients with a dropout rate of ~10% 
 
Primary Endpoint: Progression-free survival (PFS)  
 
Secondary Endpoints: 
 Objective response rate (CR+PR) by RECIST criteria 
 Disease control rate (CR+PR+SD) and duration of response  
 Median time to progression (TTP) and overall survival (OS) 
 Safety profile of pemetrexed and erlotinib combination 
 Laboratory correlative studies (Please refer to section 7 and Appendix D and E for further 
instructions) 
 
 Treatment will be repeated every 21 days (one cycle) until evidence of disease progression, 
intolerable toxicity, withdrawal of informed consent, or death.  
 Tumor measurement will be repeated every 2 cycles (6 weeks) during the first year and every 
3 cycles (9 weeks) after the first year in both arms. 


 
1
1. OBJECTIVES 
 
1.1. 
The primary objective is to evaluate progression free survival (PFS) in the schedule-
modulated concomitant administration of erlotinib and pemetrexed, and in single 
agent pemetrexed in patients with advanced NSCLC as second-line chemotherapy.  
 
1.2. 
The secondary objectives are: 
1.2.1. To evaluate antitumor objective response rate (CR+PR) per RECIST criteria. 
1.2.2. To evaluate disease control rate (response rate + stable disease, i.e., 
CR+PR+SD) and duration of response. 
1.2.3. To evaluate median time to progression (TTP) and overall survival (OS) 
1.2.4. To evaluate the safety profile of concurrent pemetrexed and erlotinib versus 
single agent pemetrexed.  
 
1.3. 
The correlative studies are: to determine several molecular and cellular biomarkers 
in the tumors, the skin and the serum that are predictive of the efficacy of 
pemetrexed and erlotinib. Formalin-fixed, paraffin-embedded tumor (FFPE) blocks 
from diagnosis, fresh frozen tumor samples, skin samples, and peripheral blood will 
be collected from study patients who consent to these studies at the time of pre- and 
post-treatment.   
 
2. BACKGROUND 
 
2.1  
Treatment for Advanced NSCLC 
Lung cancer remains the leading cause of cancer death throughout the world. Non-small cell 
lung cancer (NSCLC) accounts for more than 80% of all cases of lung cancer in the United 
States. Despite significant improvement in treatment modalities, NSCLC patients who present 
with locally advanced or metastatic disease have a dismal prognosis [1, 2]. In patients who are 
candidates for first-line cytotoxic chemotherapy, the clinical benefit of conventional cytotoxic 
chemotherapy (platinum doublets or non-platinum doublets) has reached a plateau of a median 
survival of 7.8 months [2, 3]. Combining new molecularly targeted therapies after the first-line 
combination cytotoxic chemotherapy [4] or combining molecularly targeted agent with first-line 
cytotoxic chemotherapy doublets (E4599) [5] has extended the median overall survival to over 
12 months with symptomatic improvement in patients with advanced NSCLC.  
 
Currently, 40-60% of patients with advanced NSCLC benefit from chemotherapy for disease 
control and symptom palliation during the course of their disease. Prior to May 2004, docetaxel 
(Taxotere; Aventis Pharmaceuticals) was the only FDA-approved second-line chemotherapy 
agent for patients with advanced NSCLC. Although the response rate is <10%, docetaxel 
increases the 1-year survival from 10% to 20% (from the time of study entry) and improved the 
quality of life when compared with best supportive care or old second-line chemotherapies [6, 7]. 
Our improved understanding of tumor biology and genetics, including the identification of 
critical genes related to the pathogenesis of NSCLC, has led to the development of several novel 
agents against the established cytotoxic targets and novel molecular targets. Several targeted 
agents have been introduced into the management of patients with NSCLC, mainly with 
advanced disease. Pemetrexed and erlotinib represent the two best examples of these novel 
agents that have been recently approved by the U.S. FDA for the single agent second-line 
therapy of advanced NSCLC [8, 9]. Further mechanistic studies are needed in order to select 


 
2
small subsets of patients that may benefit from each agent, or to improve the clinical efficacy by 
combining these drugs with other agents. 
 
2.2  
Pemetrexed (Alimta®) for Advanced NSCLC 
 
Pemetrexed (Alimta®, formerly LY231514, Eli Lilly and Company, Indianapolis, IN) is a 
novel multi-targeted antifolate that is primarily an inhibitor of thymidylate synthase (TS) with 
potent, but lesser, inhibition of glycinamide ribonucleotide formyl transferase (GARFT) and 
dihydrofolate reductase (DHFR), reactions required for DNA synthesis. The rational design and 
development of pemetrexed highlight the success of our improved understanding of the 
mechanisms of resistance to antifolates over several decades [10, 11]. Pemetrexed has a unique 
6-5 fused pyrrolo[2,3-d]pyrimidine nucleus that is not present in other antifolates such as 
methotrexate and raltitrexed. Pemetrexed has favorable membrane transport properties and gains 
entry to the cell mostly via reduced folate carrier (RFC), or via a not yet fully characterized 
carrier in low pH optima [12, 13]; to a lesser extent via membrane folate binding protein 
transport systems (folate receptor α and β).[14] Once in the cell, pemetrexed is converted to 
polyglutamate forms by the enzyme folypolyglutamate synthetase (FPGS). The pentaglutamate 
form of pemetrexed is the predominant intracellular form and is 60-100-fold more potent than 
the monoglutamate in its inhibition of thymidylate synthase (TS), with inhibition constants (Ki’s) 
of ~1 nM.  Polyglutamation is a time- and concentration-dependent process that occurs in tumor 
cells and, to a lesser extent, in normal tissues [15]. Thus, pemetrexed has prolonged drug action 
in tumor cells. Inhibition of TS results in a decrease in thymidine, a pyrimidine necessary for 
DNA synthesis. Pemetrexed weakly inhibits DHFR, which is required to reduce the 
dihydrofolate to tetrahydrofolate, generated in the synthesis of thymidylate by TS. The rapid and 
marked suppression of TS by pemetrexed obviates the need for DHFR suppression in most of the 
cases.  Pemetrexed also weakly (30-200 times less potent than TS) inhibits GARFT (with a Ki’s 
of ~50 nM), which is involved in purine synthesis. In tumor cells that are exposed to a high dose 
of pemetrexed [16], or that have TS amplification [17], or that have a defect in RFC [18], 
inhibition of these folate-dependent enzymes for purine synthesis has been related to the 
cytotoxicity of pemetrexed. Glutamyl hydrolase (GH) catalyzes the degradation of inter- and 
intracellular polyglutamates. All these targets implicated in the transport, activation, metabolism, 
and mechanism of pemetrexed are potential biomarkers for the clinical activity of pemetrexed. In 
addition, deficiency in methylthioadenosine phosphorylase (MTAP) and folate (as indicated by 
an elevated plasma homocysteine concentration) was suggested to correlate with pemetrexed 
toxicity [15, 19]. The significance of these enzymes/proteins in determining the clinical response 
to pemetrexed and erlotinib has not been evaluated carefully in published studies.  
 
 
Preclinical data suggest that pemetrexed has broad spectrum cytotoxic antitumor activity in a 
variety of solid tumors, including NSCLC [20]. In phase I studies, three dosing schedules were 
explored: daily x 5 every 3 weeks, weekly x 4 on a 6-week cycle, and once every 3 weeks [21]. 
The dose limiting toxicity on all schedules was hematological, particularly neutropenia. Other 
side effects included fatigue, diarrhea, mucositis, cutaneous rash, and transient transaminitis. The 
addition of folate and vitamin B12 supplement resulted in a significantly lower incidence of 
hematological and non-hematological toxicity without compromising the antitumor efficacy of 
pemetrexed [22]. The once-every-3-week schedule was the most convenient and had the highest 
response rate, and thus it was selected for further clinical development. The maximum tolerated 
dose was 600 mg/m2 as a single agent, and 500 mg/m2 in combination with other 
myelosuppressive cytotoxic agents, such as cisplatin, carboplatin, paclitaxel, gemcitabine and 
oxaliplatin [20]. 


 
3
 
Single agent pemetrexed has first-line and second-line activity against advanced NSCLC. 
Phase II studies have shown significant efficacy (overall response rate) of 39-45%, median 
survival of 8.9-10.9 months, 1-year survival of ~50%, and median duration of response of 6.1 to 
10.4 months and a favorable toxicity profile of the combination of pemetrexed plus platinum 
without vitamin supplementation as first-line therapy for NSCLC [23, 24]. Second-line activity 
against NSCLC was demonstrated in a multi-center, randomized, open label phase III trial 
comparing single-agent pemetrexed with docetaxel. In that trial, overall response rate (9.1% 
versus 8.9%), median progression-free survival (2.9 months per arm, with a hazard ratio of 0.97), 
time to progression (3.4 versus 3.5 months, with a hazard ratio of 0.97), 1-year survival (29.7% 
per arm), and median overall survival (8.3 versus 7.9 months, with a hazard ratio of 0.99) were 
comparable between pemetrexed and docetaxel (Table 1). Although the study failed to show a 
statistically significant overall survival superiority or non-inferiority of pemetrexed, the side 
effects (grade 3 or 4 neutropenia: 5.3% versus 40.2%; febrile neutropenia: 1.9% versus 12.7%; 
use of granulocyte colony-stimulating factor support: 2.6% versus 19.2%) were significantly less 
for patients who received pemetrexed [25]. Pemetrexed has been combined with cisplatin, 
carboplatin and oxaliplatin, and promising clinical activity has been demonstrated in Phase II 
studies in advanced NSCLC, with modest toxicity. In summary, pemetrexed has a higher 
response rate and longer duration of response in the first-line setting, and lower level of 
hematologic and non-hematologic toxicity even in the second-line setting for advanced NSCLC. 
It is worthy of further study in combination with other drugs. 
 
  
Vitamin supplements with pemetrexed treatment. In early clinical development, pemetrexed was 
administered without vitamin supplements and was associated with significant mucosal and bone 
marrow toxicity. Increases in plasma homocysteine and cystathionine concentrations are 
associated with lower nadir ANC. Subsequent co-administration of low level dietary supplement 
of folic acid and vitamin B12 has significantly decreased the mucosal and bone marrow toxicity 
of pemetrexed without compromising its antitumor effect. Co-administration of oral folic acid or 
intramuscular vitamin B12 does not affect the pharmacokinetics of pemetrexed [26]. Although 
the mechanisms underlying remain elucidated, preclinical studies in murine models suggest that 
changes in dietary folate intake can modulate high affinity folate receptor isoform expression and 
FPGS activity in different organs and tumor cells. These data support that the tissue distribution 
and toxicities of classical antifolates requiring polyglutamation for activation and cellular 
retention will be influenced significantly by folate status of the host [27, 28]. Most of our 
patients prefer to take multivitamin (MVI) supplement and most of the commercial MVIs 
contain 400 mcg folic acid. To control the variation of folic acid supplement, we would 
recommend the study patients only taking the folic acid supplement in a form of MVI.  
 
2.3  
EGFR Signaling Transduction Pathway and Erlotinib HCL (Tarceva®) in 
NSCLC 
 
Epidermal growth factor receptor (EGFR, also known as HER1 or erb B) is a member of the 
ErbB tyrosine kinase receptor family, which also includes HER2, HER3, and HER4. The ErbB 
receptors are present in the plasma membrane and share a common structure composed of an 
extracellular ligand-binding domain, transmembrane segment, and an intracellular tyrosine 
kinase domain. ErbB receptors are activated by a variety of receptor-specific ligands including 
epidermal growth factor (EGF), transforming growth factor-alfa (TGF-α), amphiregulin, heparin-
binding EGF (HB-EGF), epiregulin, neuregulin, and betacellulin. As a result of ligand binding, 
receptor dimerization, trans-autophosphorylation, and initiation of signaling occur. Several major 
signaling pathways mediate the downstream effects of EGFR activation: the cell proliferation 


 
4
pathway (Ras/Raf/MAP kinase), and survival pathway [phosphatidylinositol 3-kinase 
(PI3K)/Akt and Jak/Stat or protein kinase C (PKC)]. Many carcinogenic processes are mediated 
by EGFR signaling including cell survival, proliferation, angiogenesis, and invasiveness.  
 
 
The rationale for targeting HER1/EGFR for NSCLC treatment is as follows: 1) 40-80% of 
NSCLC express HER1/EGFR by immunohistochemistry staining; 2) HER1/EGFR is frequently 
dysregulated in many solid tumors, including NSCLC [29, 30]; 3) HER1/EGFR activation 
initiates a signal transduction cascade that promotes tumor-cell proliferation and survival; 4) 
Overexpression/dysregulation of HER1/EGFR is associated with poor prognosis; 5) 
Overexpression of HER1/EGFR can transform cells in a ligand-dependent manner; and 6) 
HER1/EGFR blockade inhibits tumorigenicity [31]. At least 4 mechanisms are implicated in 
dysregulation of EGFR pathways: overproduction of growth factors, over expression of growth 
factor receptors, ligand-independent receptor activation, and initiation from cross-talk of other 
messenger substances, such as hormones and neutrotransmitters. Accordingly, targeted therapies 
directed at each of the mechanisms have been developed in clinical trials [32].  
 
Erlotinib (Tarceva® formerly OSI-774), a quinazoline derivative, is a potent and highly 
selective, small tyrosine kinase inhibitor that blocks the intracellular tyrosine kinase 
autophosphorylation, and subsequently prevents the receptor-mediated signaling pathways. It 
reversibly competes with the adenosine triphosphate (ATP) at the ATP-binding site within the 
intracellular tyrosine kinase (TK) domain of the EGFR protein. Its mechanisms of action and 
clinical development have been extensively reviewed [31]. Erlotinib inhibits the growth of tumor 
cells, interferes with cell cycle progression, causing accumulation in G1 phase, and induction of 
apoptosis of a variety of tumor cell lines in vitro and in vivo [33]. In phase I studies, the 
recommended phase II dose and schedule was 150 mg daily by mouth. The minimum plasma 
steady-state concentrations was above the targeted concentration at 1.20  0.62 g/mL, and the 
mean half-life was about 24 hours. The most common side effects and dose-limiting toxicities 
were skin rash and diarrhea [34, 35]. Perez-Soler et al reported that erlotinib has a single agent 
activity of 12.3% in 57 EGFR+ patients with advanced NSCLC who failed first-line cisplatin-
containing chemotherapy [36]. Treatment was well tolerated, the most common adverse effect 
being a maculopapular acneiform rash in 44 pts (78%). In 731 EGFR unselected patients, a 
double-blind, international, randomized trial (BR.21) comparing erlotinib 150 mg by mouth daily 
to placebo, erlotinib had a response rate of 8.9%, as compared to the placebo had a response rate 
of less than 1 percent (p <0.001). The median duration of the response was 7.9 months and 3.7 
months, respectively. Progression-free survival was 2.2 months and 1.8 months, respectively 
(hazard ratio, 0.61, adjusted for stratification categories; P<0.001). Overall survival was 6.7 
months and 4.7 months, respectively (hazard ratio, 0.70; P<0.001), in favor of erlotinib. Five 
percent of patients discontinued erlotinib because of toxic effects (Summary in Table 1) [37, 
38]. On November 18, 2004, the FDA approved erlotinib for treatment of patients with locally 
advanced or metastatic NSCLC after failure of at least one prior chemotherapy regimen.  
 
Although single agent activity of erlotinib in NSCLC has been confirmed, results from phase 
III randomized trials in patients with NSCLC reveal no additional benefit of erlotinib added to 
standard combination therapy carboplatin and paclitaxel, despite preclinical synergism of 
erlotinib with many cytotoxic agents has been demonstrated. Many mechanisms have been 
proposed, including the timing of administration of erlotinib with chemotherapy, patient 
selection, tumor selection, suboptimal dosage and drug delivery schedule that leads to ineffective 
downstream molecular inhibition of EGFR. More importantly, the preclinical targets of erlotinib 


 
5
or other anti-EGFR agents have not been prospectively validated in the clinic, especially in 
EGFR-containing combinational therapies. Our laboratory and others have been interested in 
determining clinical, molecular and cellular determinants for response in the past few years. 
Several clinical predictors of response were observed: never smoker, female gender, 
adenocarcinoma histology (especially bronchioalveolar adenocarcinoma), and Japanese versus 
American/Europeans. To this end, several cellular and molecular determinants were also 
demonstrated: the presence of EGFR intracellular tyrosine kinase domain mutations, and 
hyperactivated downstream signaling pathways, such as phosphorylated MAPK (p-MARK) or 
phosphorylated AKT (p-AKT). Several studies reported that the presence of two “hot spot” 
mutations in the exons 19 and 21 of EGFR TK domain correlated with the increased sensitivity 
(~80%) to EGFR-TKIs [39-43], and the prevalence of this mutation is more present in 
Japanese/Chinese over Americans [39, 44]. However, there are no mutations present in most 
NSCLC patients that have stable disease in response to EGFR-TKIs. Other mechanisms must be 
accountable for this population of patients. 
 
Table 1. Clinical benefit of erlotinib and pemetrexed-containing in second-line NSCLC therapies. 
 
Drug: 
Erlotinib 
Erlotinib 
Pemetrexed 
Pemetrexed 
Erlotinib 
+Bevacizumab 
Reference: First author 
 (Year of Publication) 
Perez-Soler 
 (2004) [36] 
Shepherd  
(2005) [38] 
Hanna 
 (2004) [25] 
Smit  
(2003) [45] 
Herbst  
(2005) [4] 
Phase 
II 
III 
III 
II 
I/II 
Dosage and Dosing Schedule 
150 mg QD 
 
150 mg QD 
500 mg/m2 IV 
Day 1 of 21-day 
cycle 
500 mg/m2 IV 
Day 1 of 21-day 
cycle 
150 mg QD x 
21days; 7.5-15 
mg/kg bev 
Number of Patients: 
57 
Erlotinib: 488 
Pemetrexed: 283 
 
40 
EGFR positive/unknown: 
+ 
nonselected 
N/A 
 
nonselected 
Prior First-Line Cisplatin-Containing 
Chemotherapy  
55% 
93% 
92.6% 
 
 
Prior Second-Line Chemotherapy 
15% 
50% 
22/40 
 
 
Prior Chemotherapy: 
 
 
66% 
 
 
Duration of Clinical Benefit:  
Clinical Benefit Rate (%):(95% CI) 
  CR (%) 
  PR (%): 
  SD (%): 
 
47.4%-50.9% 
3.5 % 
8.8% 
35.1%-38.6%* 
 
 
- 
8.9% 
(versus 0.9%)  
5.4 (1.2-18.2) mo. 
54.9% 
- 
9.1% 
45.8% 
 
 
8.9% 
 
65%(50.2-79.8) 
20% (7.6-32.4) 
 
Median PFS: 
(95% CI) 
9  
(8-15) wks 
2.2  
(0.5-18.2) mos. 
(9.9 vs 7.9 wk, 
HR 0.59) 
2.9  
(0-18.2) mos. 
 
6.2 mos. (7 
mos. for phase 
II portion) 
Median Duration of Response: 
(95% CI) 
 19.7  
(11.7-80.3) wks 
34.2 (vs 5.9) 
wks 
4.6  
(2.1-15.3) mos. 
 
 
Median Survival 
(95% CI) 
8.4  
(4.8-13.9) mos. 
6.7 (vs 4.7) mos., 
HR 0.73 
8.3  
mos. 
5.7  
mos. 
12.8  
mos. 
1-yr Survival 
(95% CI) 
40% 
 (28% to 54%) 
31.2% 
(vs 21.5%) 
29.7% 
 
 
Toxicity: 
  Skin rashes (any/grade 3-4): 
  Diarrhea (any/grade 3-4): 
  Neuropathy (any/grade 2-3) : 
Hematologic: 
  Grade 3-4 neutropenia/febrile : 
  Grade 3-4 thrombocytopenia : 
  Grade 3-4 anemia : 
 
67%/1% 
56%/1% 
11%/0% 
rare 
 
76%/9% 
55%/6% 
 
 
5.1% 
<1.9% 
<2.4% 
 
14%/0.8% 
12.8%/0.4% 
4.9%/0% 
 
5.3%/1.7% 
1.9% 
4.2% 
 
 
Abbreviations: CI, confidence interval; CR, complete remission; PR, partial remission; SD, stable disease; PFS, 
progression-free survival; wks, weeks; mos, months. 
 


 
6
Data from our laboratory suggest that acquired resistance to erlotinib is associated with 1) 
marked downregulation of total and activated HER1/EGFR; 2) overexpression of genes involved 
in other signaling pathways, such as K-Ras mutation; 3) rare, cross-resistance to common 
cytotoxic agents [46]; 4) increased sensitivity to erlotinib in chemo-resistant cell lines as 
compared to parental cell lines in vitro and in vivo [47].  This increase in sensitivity to erlotinib 
correlated with increased expression of pEGFR and total EGFR, suggesting that tumors resistant 
to conventional chemotherapy agents would likely become more dependent on the EGFR 
signaling pathway for growth and survival. These preclinical data are consistent with the clinical 
experience that erlotinib or gefitinib are active in patients who are refractory to chemotherapy. 
Several clinical studies evaluate the role of erlotinib in different stages of lung cancer treatment, 
with correlative studies to determine the molecular determinants of sensitivity or resistance to 
erlotinib treatment. Thus, the study proposed in this application is within the scope of this global 
effort and will target patients with advanced NSCLC.  
 
2.4  
Rationale for the Proposed Clinical Study 
 
Rationale for optimizing drug delivery sequence. Despite proven single agent activity, 
addition of erlotinib or other EGFR inhibitors to first-line cytotoxic chemotherapy agents has 
failed to improve the clinical outcomes in patients with advanced NSCLC in several large 
randomized controlled studies [48-51]. Several hypotheses have been proposed to explain this 
phenomenon. We hypothesize that one possible solution is to optimize the proper delivery 
sequence of erlotinib and pemetrexed. Skipper et al first proposed the concept of modulating 
drug delivery schedule based on cell cycle effect in the 1960’s [52, 53]. This principle has 
surprisingly not been used more often for designing clinical combination therapies until recently 
(also several reports at ASCO 2005). Fine et al found that although phase I study of combination 
of gemcitabine (G, Gemzar), docetaxel (T, Taxotere) and capecitabine (X, Xeloda) (GTX) had 
activity in patients with refractory pancreatic cancer, alternating T-GX delivery schedule based 
on their in vitro data of separating G1/S agents (gemcitabine, capecitabine) from G2/M agents 
(docetaxel) overcame the drug resistance with better tolerability in patients who failed GTX [54, 
55]. A phase II study is being conducted to confirm this result [56]. More relevantly, 
combination studies of pemetrexed and gemcitabine confirmed that sequence of drug delivery 
affects the antitumor activity in the preclinical and clinical studies [57-62]. Ma et al recently 
reported the results of a randomized three-arm phase II study evaluating the optimum 
administration schedule of pemetrexed and gemcitabine in chemotherapy-naive patients with 
advanced NSCLC [59]. Patients were randomly assigned to three schedules as follows: schedule 
A, pemetrexed followed by gemcitabine on day 1 and gemcitabine on day 8; schedule B, 
gemcitabine followed by pemetrexed on day 1 and gemcitabine on day 8; and schedule C, 
gemcitabine on day 1 and pemetrexed followed by gemcitabine on day 8. They found that 
schedule A had the highest response rate of 31%, compared with schedules B and C, with 
response rates of 6.5% and 16.1%, respectively. Schedule B was discontinued after interim 
analysis because of a poor response rate. Regarding toxicities, schedule A resulted in less severe 
toxicity compared with schedule C. Schedule B, which had the lowest response rate, had the 
highest incidence of grade 3 and 4 febrile neutropenia (schedules A, B, and C: 5%, 19%, and 5%, 
respectively). The median survival time (schedules A, B, and C: 11.4, 10.3, and 11.8 months, 
respectively) and TTP (schedules A, B, and C: 4.7, 4.1, and 4.4 months, respectively) were 
similar among the three schedules, consistent with a number of recent comparative combination 
studies for advanced NSCLC, in which improvement in objective response did not translate to 
improvement in survival or TTP. The most likely explanation is that patients in schedule B or C 


 
7
received other effective treatment after the protocol treatment. This is the first and best 
randomized phase II study so far to test the clinical efficacy of optimizing the administration 
schedule of two chemotherapy agents and have demonstrated that the schedule of administration 
of certain chemotherapy agents may be important in terms of toxicity and, potentially, efficacy. 
These data support proceeding with the preclinical and clinical testing of optimizing the drug 
delivery sequence for combining a molecularly targeted agent with cytotoxic chemotherapy. 
 
Rationale for the schedule-modulated combination of pemetrexed and erlotinib. We have 
demonstrated that although pemetrexed alone activates the EGFR signaling transduction 
pathway, addition of erlotinib abrogates pemetrexed-induced activation of EGFR pathway in 
both erlotinib-sensitive and –resistant human NSCLC cells. The cytotoxic synergism is greater in 
erlotinib-resistant (combination index, CI, 0.75) than erlotinib-sensitive (CI, 0.25) human 
NSCLC cells. The best cytotoxic synergism was achieved by administering pemetrexed followed 
by erlotinib in both erlotinib-sensitive and erlotinib-resistant NSCLC cell lines. This cytotoxic 
synergism was associated with induction of apoptosis and cell cycle arrest in the G1 and G2/M 
phases of the cell cycle [63] . It is worthy to emphasize that while there is no significant 
difference in the cytotoxicity of pemetrexed alone, addition of pemetrexed to erlotinib sensitizes 
the erlotinib-resistant cells to both agents and leads to comparable maximal synergistic 
cytotoxicity in erlotinib-sensitive NSCLC cells. Based on these results, the combination of 
pemetrexed and erlotinib might overcome the resistance to erlotinib alone and leads to the same 
synergistic cytotoxicity. This could be particularly important for the 90% of patients with wild-
type EGFR gene in the U.S. who are resistant (mimic clinical patients that are resistant) or less 
responsive (mimic clinical patients that have stable disease) to single agent anti-EGFR therapy. 
The addition of pemetrexed to erlotinib could make these patients benefit equally from both 
agents as compared to those patients that are responsive to both of the single agents.  
 
Rationale for the sequential administration of pemetrexed followed by erlotinib in the 
extended study.  No study has compared the clinical efficacy of concurrent pemetrexed and 
erlotinib versus single agent pemetrexed in patients with advanced NSCLC after first-line 
combinational therapy. In fact, no studies have ever demonstrated any clinical benefit of 
cytotoxic combination, either with other cytotoxic agent or with novel molecularly targeted 
agents, in patients with advanced NSCLC as a second-line treatment. Thus, we propose to first 
compare the PFS of schedule-modulated concomitant administration of pemetrexed and erlotinib 
to single agent pemetrexed in the current study. In breast cancer, at least two studies have 
demonstrated the survival benefit of combinational chemotherapy over single agent 
chemotherapy, although it is associated with higher toxicities and might be equivalent to the 
sequential single agent therapy [64-66]. There is no defined standard therapy for advanced 
NSCLC patients after the first-line combinational therapy. The choice of pemetrexed, docetaxel, 
or erlotinib varies significantly in physicians and patients. Many new molecularly targeted agents 
have shown promise in improving the treatment outcome in this patient population. This could 
be a compounding factor that might influence the interpretation of the current study, as discussed 
in details in the previous section [59]. Thus we would like to design an extension study of single 
agent erlotinib for all patients who have progressed on or cannot tolerate pemetrexed. This is 
consistent with current acceptable clinical practice: to give the intravenous cytotoxic therapy 
before the less toxic and oral administrated erlotinib when the patients’ performance status and 
organ function are still good. The sequence of pemetrexed followed by erlotinib is supported by 
our previous study which demonstrated that increased sensitivity to erlotinib was observed at 
least in some chemo-resistant human NSCLC cell lines. In the erlotinib registration (BR.21) 


 
8
study, 50% of patients had received 2 or more prior chemotherapy regimens, and similar clinical 
benefit was observed in these patients as compared to those patients who received only one prior 
chemotherapy [38]. Thus, we would choose the single agent pemetrexed over single agent 
erlotinib in the control arm (Arm A) in the current study. We intend to explore the clinical 
benefit of sequential pemetrexed and erlotinib by enrolling patients in Arm A after they fail 
single agent pemetrexed into the extended study of single agent erlotinib. We would estimate the 
overall survival between the concurrent versus sequential pemetrexed and erlotinib after the 
protocol.  Since the sample size is very small, it is only an exploratory study for hypothesis 
generating future study. 
 
Rationale for dose escalation of erlotinib in Arm B (the Concomitant Arm). Although well 
tolerated with most transient grades 1-2 toxicities, we have not observed significant objective 
response in patients receiving pemetrexed and erlotinib combination in our study. The safety of 
the same schedule of erlotinib and pemetrexed combination in solid tumor was recently reported 
[67].  Recommended phase II dose was pemetrexed 500 mg/m2 on day 1 and erlotinib 250 mg 
days 2-16 every 3 weeks. We thus propose to revise the protocol to allow dose escalation of 
erlotinib by 50 mg in the combination arm if patients have tolerated the treatment and have stable 
disease after 2 cycles of treatment. The maximal dose of erlotinib is 250 mg with less than grade 
2 toxicities. 
In addition, cigarette smoking has been shown to reduce erlotinib exposure. Of the first 22 
evaluable patients accrued in the study, nineteen were ex-smoker with a history of cigarette 
smoking for more than 15 pack-years and two were active smokers. According to the 
manufacture, patients should be advised to stop smoking. If a patient continues to smoke, a 
cautious increase in the dose of TARCEVA, not exceeding 300 mg may be considered, while 
monitoring the patient’s safety. If the TARCEVA dose is adjusted upward, the dose should be 
reduced immediately to the indicated starting dose upon cessation of smoking. We thus propose 
to revise the protocol to allow erlotinib dose escalation to 300 mg PO daily in smokers.  
 
2.5 
Rationales for Correlative Studies 
 
Molecular and Cellular Determinants of erlotinib   Several clinical predictors for response 
were observed in patients receiving anti-EGFR therapy: never smoker or light smoker, East 
Asians, female gender, adenocarcinoma histology (especially bronchioalveolar adenocarcinoma), 
the presence of skin rashes, and a history of prior immunologic or hormonal therapy. The 
molecular or cellular basis for these clinical predictors is largely unknown. Although the 
expression of EGFR status in patients does not correlate with survival or response in most of the 
clinical studies, we found that the resistance of NSCLC cells with either wild-type or mutated 
EGFR accompanied the loss of EGFR gene as determined by Western blots. Further mechanistic 
studies are ongoing in our laboratory. Several molecular and cellular determinants were 
suggested in the preclinical and clinical studies: the presence of sensitive or resistant mutations 
in the intracellular tyrosine kinase domain of EGFR, the absence of K-Ras mutation in patients 
with EGFR mutation, and hyperactivated downstream signaling pathways, such as 
phosphorylated MAPK (p-MAPK) or phosphorylated AKT (p-AKT). The most controversial 
issue is the role of EGFR mutations in predicting response to anti-EGFR therapy and prognosis 
of NSCLC patients. Several studies reported that the presence of two “hot spot” mutations in the 
exons 19 and 21 of EGFR TK domain correlated with the increased sensitivity (~80%) to EGFR-
TKIs [39-43], and the prevalence of this mutation is 2-3 fold higher in Japanese/Chinese over 


 
9
Americans [39, 44]. But these mutations are seldom found in NSCLC patients that have stable 
disease in response to anti-EGFR therapy. Other mechanisms must be accountable for this 
population of patients. Our laboratory has previously demonstrated that: 1) there was no cross-
resistance between erlotinib and common cytotoxic agents in vitro and in vivo [47]; 2) at least in 
some human NSCLC cell lines, acquired resistance to cytotoxic chemotherapy is accompanied 
with increased EGFR expression and subsequently increased sensitivity to erlotinib [68]; 3) the 
basal levels of activated downstream EGFR signal molecules (phosphorylated ERK1/2 and AKT 
proteins) correlate with the sensitivity or resistance to erlotinib better than the levels of 
phosphorylated EGFR/total EGFR [68]; and 4) NSCLC cell lines that harbor EGFR mutation 
have differential in vitro cytotoxic sensitivity to pemetrexed that are not related to their 
differential sensitivity to erlotinib [63]. The clinical and molecular determinants for pemetrexed 
are largely unknown currently. These data suggest that the presence of EGFR mutation in 
NSCLC cells alone is not enough to determine the sensitivity to other cytotoxic 
chemotherapeutics such as pemetrexed. Thus, we propose correlative studies to determine the 
molecular and cellular determinants of patients who might respond to pemetrexed or erlotinib.  
 
Expression of Epithelial to Mesenchymal Transition (ETM) Markers and Sensitivity to 
Erlotinib   The expression of epithelial cell markers (such as E-cadherin, β-catenin) correlates 
with the sensitivity of NSCLC cells containing wild-type EGFR to erlotinib, whereas the loss of 
these epithelial cell markers expression and the expression of EMT markers (such as vimentin 
and/or fibronectin) correlate with resistance to erlotinib in in vitro and in vivo models [69, 70]. 
Furthermore, a small retrospective analysis of E-cadherin immunohistochemistry (IHC) 
expression on primary tumor samples from NSCLC patients suggests that the strong E-cadherin 
expression was associated with a significantly longer time to progression (n=28 and 37, 
respectively; hazard ratio, 0.37; log rank P=0.0028) and a nonsignificant trend toward longer 
survival with erlotinib plus chemotherapy treatment versus chemotherapy alone [70]. We thus 
propose to determine the E-cadherin, vimentin and fibronectin expression by IHC in tumor 
specimens obtained from NSCLC patients enrolled in this study, and to correlate the level of 
expression with clinical efficacy.  
 
Smoking and Response to Erlotinib in Patients with NSCLC   A history of significant 
smoking (>15 packs per year) has been suggested as one of the strongest clinical predictors for 
the response to EGFR inhibitors [71, 72]. Its role in predicting response to cytotoxic 
chemotherapy is less well defined. Accumulating data suggest that the inherited gene signature 
and functional cellular proteins of tumor cells determines their biological behaviors of growth, 
differentiation, survival, and metastasis and are critical for the sensitivity to therapeutic 
interventions. Cigarette smoking and increased exposures to industrial hazards are responsible 
for the 85-90% of patients with lung cancer in the United States. Many carcinogens, such as 
polycyclic aromatic hydrocarbons (PAH) and nitrosamines, are present in tobacco smoke. 
These carcinogens transform normal cells via the formation of DNA adducts in target tissues 
and multiple genetic mutations in transforming genes, including K-Ras and p53 genes [73]. 
Some molecular alterations are already detectable before morphologic changes are apparent in 
the bronchial mucosa by light microscopy. Mutations in the p53 tumor suppressor gene or K-
Ras oncogene are the most prevalent mutations found in human cancers, including in 33% of 
p53 mutations and 20-40% of K-Ras mutations in the lung adenocarcinoma. The frequency of 
the p53 mutation correlates with a higher average DNA adducts level in the lung tumors. 
Several inconsistent studies support a relationship between p53 or K-Ras mutations and the 
development, progression, or drug resistance of tumors. But they are hard to interpret since the 


 
10
smoking status, treatment effect and analysis techniques are not controlled. Greater than 90% 
of p53 mutations are reported as single amino acid substitutions within the central core domain 
of DNA binding (exons 5-8). The p53 mutations provide tumor cells with a selective growth 
advantage such as G2 checkpoint deficiency. K-Ras is a downstream signaling molecule in the 
EGFR signaling pathway. Most common mutations are missense mutation at codons 12, 13 and 
61 in exon 1 and 2 of Ras gene, with the highest incidence of mutations in codon 12 of the K-
Ras oncogene in adenocarcinoma. Most mutations characterized for Ras gene result in 
stabilization of the GTP-bound, active form of RAS. Our preclinical data and other studies on 
the mutation status of K-Ras and p53 genes in a panel of NSCLC cell lines suggest that both 
K-Ras and p53 mutations might be exclusively expressed with EGFR mutation. Patients whose 
tumors have K-Ras mutations might have a poor prognosis when erlotinib is given with 
chemotherapy, supporting the antagonistic effect observed early in the TRIBUTE study [74].  
 
In contrast to the old belief that the amount of cigarette smoking determines the amount of 
p53 or K-Ras gene mutations in patients with NSCLC, new data suggest specific EGFR 
mutations that are present exclusively in non-smokers or light smokers. These results suggest 
that NSCLC tumors in smokers and non-smokers have distinct tumor biology that result from 
completely different molecular pathways. Heterozygous somatic mutations observed most are 
deletions or amino acid point mutations in exons 18, 19, and 21 of the EGFR gene, and are 
associated with increased sensitivity of NSCLC cells to erlotinib or gefitinib. Although the 
mechanisms underlying this phenomenon are unknown, this important information sheds light 
for refining personalizing strategies for lung cancer therapy. More interestingly, a secondary 
resistant mutation in patients with primary EGFR mutations was identified (T790M) [75, 76]. 
This mutation occurs in an analogous position to previously described secondary mutations in 
BCR-ABL, PDGFR-alpha, and c-kit that are associated with resistance to imatinib, which could 
be overcome by one other EGFR inhibitor, CL-387,785. The role of somatic mutations in EGFR 
in determining the sensitivity to cytotoxic agents is controversial and is not known for 
pemetrexed.  
 
Caveolin-1 (Cav-1) and NSCLC   Caveolin-1 (Cav-1) is an essential structural component of 
cell surface caveolae, whose structural integrity is essential for many signaling processes 
including EGFR and estrogen receptor (ER). Down-regulation of Cav-1 gene has been 
implicated in several tumors including lung cancer. A recent report revealed that Cav-1 
expression in adenocarcinoma was significantly lower in never smokers compared to those in 
recent smokers [77]. Several additional evidence suggests that cav-1 is functionally related to the 
function of EGFR: 1) activation of Cav-1 by EGF inhibits EGFR activation [78]; 2) absent or 
reduced Cav-1 expression is found in fibroblasts transformed by activated oncogene H-Ras 
(G12V) [79]; and 3) genetic ablation of Cav-1 expression in a mammary–gland tumor 
susceptible model is associated with increased distant metastasis to the lungs. We recently 
reported that a Cav-1 P132L somatic mutation is present in 20% of ER+ human breast cancers 
and cause complete loss-of-function of Cav-1 protein in a dominant-negative fashion. Additional 
Cav-1 mutations are present in 35% of ER+ breast cancers. The role of Cav-1 mutations in lung 
cancer is not known. We hypothesize that the Cav-1 mutations are associated with EGFR 
activation in non-smoking NSCLC patients. We will further explore their relationship with 
smoking-related gene mutations of p53 and K-Ras, and in sensitivity to erlotinib and/or 
pemetrexed.  See Appendix K  (Smoking Status Questionaire). 
 
Rash as a surrogate marker of clinical response and survival   EGFR is expressed at high 


 
11
level in the skin and play a vital role in normal physiological function and the skin. 
Dysregulation of EGFR is implicated in psoriasis, although the mechanism is poorly delineated 
and the good animal model for this disease is lacking. Treatments of all anti-EGFR therapeutic 
agents are associated with high incidence of skin changes (60-90%). Although most patients 
tolerate the rash well, severe skin rash is one of the dose-limiting toxicities and may lead to 
treatment interruption or discontinuation. Analysis of previous clinical studies suggested that the 
severity of rash correlates with survival in patients receiving erlotinib. Although the mechanisms 
for rashes are largely unknown, several ongoing studies are evaluating the relationship between 
skin and tumor EGFR expression, the relationship between the severity of skin rashes and 
clinical efficacy. Our unpublished data suggest that acute inflammatory reaction is present in the 
skin of mice that have received oral erlotinib treatment. However, the role of this acute 
inflammatory reaction in humans is not known.  
 
2.6 
Summary and Clinical Significance 
 
In summary, we have demonstrated that pemetrexed and erlotinib have a schedule-dependent 
(pemetrexed followed by erlotinib) synergism in vitro. This effect is present in both erlotinib-
sensitive and erlotinib-resistant human NSCLC cell lines that have wild-type EGFR gene. We 
hypothesize that the schedule-modulated combination of pemetrexed and erlotinib will improve 
the antitumor activity in patients with advanced NSCLC. The objective of this study is to 
determine the therapeutic efficacy of this schedule-modulated combination of pemetrexed and 
erlotinib in the second-line treatment of advanced NSCLC patients. In addition, we will explore 
the predictive biomarkers for the clinical efficacy of pemetrexed and erlotinib.  
 
The positive result of E4599 (carboplatin and paclitaxel ± bevacizumab as a first-line 
treatment for patients with advanced nonsquamous NSCLC), together with other encouraging 
results of bevacizumab in combination of cytotoxic chemotherapies in several solid tumors that 
have been recently published or reported would likely lead to the incorporation of bevacizumab 
in combination with carboplatin and paclitaxel as a first-line treatment for patients with advanced 
nonsquamous NSCLC. Currently, there is not sufficient data to support the continuous use of 
bevacizumab in second-line setting after prior exposure. This new information has made this 
proposed study more appropriate now as a second-line therapy for patients with advanced 
NSCLC. This highly significant project would not only prove the principle of modulating the 
drug delivery sequence for combining a molecularly targeted agent with cytotoxic chemotherapy, 
it would also serve as a backbone for further addition of other novel molecularly targeted agents. 
In addition, it would have an immediate impact on the clinical management of patients with 
advanced NSCLC. 
 
3. PATIENT SELECTION 
3.1  
Eligibility Criteria 
3.1.1 Patients must have histologically or cytologically confirmed advanced (Stage 
IIIB with a malignant pleural effusion or Stage IV disease) or recurrent 
nonsquamous NSCLC.  
 
3.1.2 Patients must have at least one measurable disease per RECIST criteria (as 
defined in Section 9.2). All sites of disease must be assessed within 4 weeks 
prior to registration. 


 
12
 
3.1.3 Patient must have disease progression after one prior combinational 
chemotherapy and/or targeted therapy other than pemetrexed or an EGFR TKI 
(such as erlotinib, gefitinib, or a second generation EGFR TKI). Prior 
monoclonal antibody against EGFR is allowed) for metastatic disease, or 
relapse while receiving adjuvant therapy, or within 12 months of completing 
adjuvant therapy. 
 
3.1.4 All patients will be screened for brain metastasis within 6 weeks prior to 
registration. Patients with treated and stable brain metastases must have been 
treated with surgery and/or radiation and are asymptomatic and are no longer 
taking corticosteroids.  
 
3.1.5 Patient must be age >18 years.  
 
Because no dosing or adverse event data are currently available on the use of 
erlotinib in combination with pemetrexed in patients <18 years of age, 
children are excluded from this study but will be eligible for future pediatric 
phase 2 combination trials. 
 
3.1.6 ECOG performance status <2 or Karnofsky >60% (See Appendix B). 
 
3.1.7 Patients must have hematological, liver and kidney function as defined below: 
 
- 
Absolute neutrophil count 
>1,500/L 
- 
Hemoglobin  
 
 
 
≥ 8.0 g/dL 
- 
Platelets 
 
 
 
 
 
>100,000/L 
- 
Total bilirubin  
 
 
 
<1.5 X institutional upper limit of normal 
(ULN), except in known hepatic metastasis, 
wherein may be <3.0 X ULN  
- 
AST (SGOT)/ALT (SGPT) <3.0 X institutional ULN, except in known 
hepatic metastasis, wherein may be <5.0 X 
ULN 
- 
Creatinine clearance  
 
>45 mL/min for patients with creatinine 
levels above institutional normal 
 
Note: All laboratory values must be obtained within 2 weeks prior to registration. 
Patients must not be pregnant or breastfeeding since there is no information regarding 
the use of these agents in this population. A negative serum or urine pregnancy test is 
required within 14 days prior to registration if pre- or perimenopausal (i.e., last 
menstrual period within one year of registration). Both pemetrexed and erlotinib are 
Class D agent with the potential for teratogenic or abortifacient effects.   Patients both 
females and males with reproductive potential (i.e. menopausal for less than 1 year 
and not surgically sterilized) must practice contraceptive measures throughout the 
study.  
 
3.1.8 Patients taking warfarin or NSAIDs are eligible.  Patients with mild to moderate 
renal insufficiency should avoid taking NSAIDs with short elimination half-lives for 


 
13
a period of 2 days before, the day of, and 2 days following administration of Alimta.  
If the patient is taking other CYP3A4 inducers or inhibitors (Appendix G), 
they must be discontinued at least one week prior to starting erlotinib. 
 
3.1.9 Ability to understand and the willingness to sign a written informed consent 
document. 
 
3.2  
Exclusion Criteria 
 
3.2.1 Patients who have had immunotherapy, hormone, chemotherapy or 
radiotherapy within 4 weeks (6 weeks for nitrosoureas or mitomycin C) prior 
to entering the study or those who have not recovered from adverse events due 
to agents administered more than 4 weeks earlier. 
 
3.2.2 Patients who have received pemetrexed or an EGFR TKI (such as erlotinib, 
gefitinib, or a second-generation anti-EGFR TKI) for their metastatic disease 
should be excluded from this clinical trial. Other molecularly targeted 
agent, including monoclonal antibody or vaccine against EGFR or 
angiogenesis inhibitor, is allowed.  
 
3.2.3 Patients may not be receiving any other investigational or commercial agents 
or therapies other than those described below with the intent to treat the 
patient's malignancy.  
 
3.2.4 Patients with uncontrolled brain metastases should be excluded from this 
clinical trial because of their poor prognosis. 
 
3.2.5 History of allergic reactions attributed to compounds of similar chemical or 
biologic composition to erlotinib or pemetrexed or other agents used in the 
study. 
 
3.2.6 Patients with 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, are ineligible. 
 
3.2.7 Uncontrolled intercurrent illness including, but not limited to, ongoing or 
active infection (such as bacteremia or active hepatitis), symptomatic 
congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or 
psychiatric illness/social situations that would limit compliance with study 
requirements. 
 
3.2.8 Patients with immune deficiency are at increased risk of lethal infections 
when treated with marrow-suppressive therapy. Therefore, HIV-positive 
patients receiving combination anti-retroviral therapy are excluded from the 
study because of possible pharmacokinetic interactions with erlotinib or 
pemetrexed or other agents administered during the study.  Appropriate 
studies will be undertaken in patients receiving combination anti-retroviral 
therapy when indicated. 


 
14
3.3  
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this 
trial.  
 
3.4 
Registration and Randomization of Patients 
 
3.4.1 Once the patient has consented for the protocol, please provide the 
stratification information to the overall P.I. Dr. Tianhong Li (email 
tianhong.li@ucdmc.ucdavis.edu,  telephone: 916-734-3772 for obtaining 
randomization from the study statistician Dr. Mimi Kim. The sequence number 
will be assigned by the overall P.I. Dr. Tianhong Li upon the approval of 
eligibility criteria.  
3.4.2 At the time of registration, all eligibility criteria must be checked. Patients 
must meet all of the eligibility requirements listed in Appendix F (Eligibility 
Checklist) (Section 3.0). 
3.4.3 A complete registration form (See Case Report Form Package or Appendix F-
Eligibility Check/Registration Form)should be faxed to and confirmed by 
Milagros Rodriquez (Fax: 718-822-0335) at the Clinical Trials Office at 
Montefiore Medical Center (Telephone: 718-904-2783) Monday through 
Friday 9:00am – 5:00pm Eastern Standard Time.  
3.4.4 Patients must not start protocol treatment prior to registration. 
3.4.5 Vitamin supplements (Vitamin B12 and MVI) could be given at the time of 
consent since patients in both arms will receive pemetrexed at least one week 
after the initiation of vitamin supplement. Pemetrexed should be given within 
14 days after registration. 
 
4. TREATMENT PLAN 
 
4.1  
Agent Administration 
 
Treatment will be administered on an outpatient basis.  Alimta® (Pemetrexed) will be 
given intravenously over 10 minutes on day 1 of each 21-day cycle. Tarceva® 
(Erlotinib) 150 mg PO is given once daily intermittently (Arm B). Tarceva® 
(Erlotinib) tablets should be taken once daily, preferably in the morning, with up to 
200 mL of water. It should be taken either one hour before or two hours after food. 
Patients should avoid grapefruit juice for the duration of the study. Each cycle will be 
21 days in length. Patients will continue on treatment until disease progression, or 
until any other criteria listed in section 4.3 are met.  
 
Appropriate dose modifications for Tarceva® (Erlotinib) and Alimta® (Pemetrexed) 
are described in Section 5.  
 
Arm A: control arm 
 Alimta® (Pemetrexed) 500 mg/m2 given as a 10-minute infusion on day 1, 


 
15
with folic acid (in MVI form) and vitamin B12 supplement;  
 Repeat every 21 days until evidence of disease progression, intolerable 
toxicity, withdrawal of informed consent, or death 
 
Arm B: concomitant arm 
 Alimta® (Pemetrexed) 500 mg/m2 given as a 10-minute infusion on day 1, 
with folic acid (in MVI form) and vitamin B12 supplement as indicated  
 Tarceva® (Erlotinib) 150 mg PO QD on days 2-17 (16 days). A pill log 
will be given to patients to record all doses taken, missed, and any side 
effect noted.(See Appendix H) 
 Repeat every 21 days for until evidence of disease progression, intolerable 
toxicity, withdrawal of informed consent, or death  
 
Premedications for Pemetrexed: 
Folic Acid 
Folic Acid (400 µg, i.e., 0.4 mg) must be given daily beginning approximately 5-7 
days prior to first dose of Alimta and continuing daily until 3 weeks after the last dose 
of study therapy.  We will provide the prescription for folic acid in multi-vitamin 
form. Patients will be advised not to take other form of multi-vitamins. 
 
Vitamin B12 
Vitamin B12 (1000 µg) will be administered as an intramuscular injection 
approximately 1 to 2 weeks prior to first dose of Alimta®, and repeated 
approximately every 9 weeks until 3 weeks after the last dose of study therapy. 
 
Dexamethasone 
Dexamethasone (4 mg of oral or equivalent) given twice daily should be taken on the 
day before, the day of, and the day after each dose of Alimta® (Pemetrexed), for rash 
prophylaxis unless medically contraindicated. 
 
 
 
 
Leucovorin 
Because folic acid and vitamin B12 supplementation has significantly reduced the 
number of episodes of Grade 4 hematologic and Grade 3/4 nonhematologic toxicities 
associated with Alimta therapy. A need for leucovorin as rescue agents is not 
anticipated. However, this section provides information should rescue be necessary.  
 
In clinical trials, leucovorin was permitted for CTC grade 4 leukopenia lasting > 3 
days, CTC Grade 4 neutropenia lasting > 3 days, and immediately for CTC Grade 4 
thrombocytopenia, bleeding associated with Grade 3 thrombocytopenia, or Grade 3 or 
4 mucositis. The following intravenous doses and schedules of leucovorin were 
recommended for intravenous use: 100mg/m2, intravenously once, followed by 
leucovorin, 50 mg/m2, intravenously every 6 hours for 8 days.   
 
4.2  
Supportive Care Guidelines 
 
All supportive measures consistent with optimal patient care will be given throughout 
the study. 


 
16
 
Growth factors: Alimta® (Pemetrexed) or Tarceva® (Erlotinib) administration has 
not been associated with a high incidence of neutropenia. The incidence of grade 3/4 
neutropenia is 5.3% and <5%, respectively. Thus, the routine use of myeloid growth 
factors is not recommended. In the case of a patient with febrile neutropenia or grade 
4 neutropenia without fever, growth factors may be utilized per investigator 
discretion. 
 
Recombinant erythropoietin may be administered for symptomatic and/or progressive 
> grade 2 anemia according to current practice guideline. 
 
Antiemesis: Suggested pretreatments could include a serotonin antagonist 
(granisetron, ondansetron), dexamethasone, and/or prochlorperazine. 
 
Bisphosphonates may be administered for bone metastasis per investigator discretion. 
 
Therapy for Patients with Diarrhea and Febrile Neutropenia: Patients experiencing 
febrile neutropenia, especially with diarrhea, should be managed in a hospital setting 
according to standard procedures, with the urgent initiation of intravenous antibiotic 
therapy. Also see section 5.2 and 5.3 for recommendations for therapy for pemetrexed 
or erlotinib-induced diarrhea. 
 
Therapy for Patients with skin rash: See section 5.3. 
 
Clinically Significant Effusions: For patients who develop or have baseline clinically 
significant pleural or peritoneal effusions (on the basis of symptoms or clinical 
examination) before or during initiation of Alimta therapy, consideration should be 
given to draining the effusion prior to dosing.  However, if, the effusion represents 
progression of disease in the investigator’s opinion, the patient should be 
discontinued from study therapy. 
 
4.3  
Duration of Therapy 
 
In the absence of treatment delays due to adverse events, treatment may continue until 
one of the following criteria applies: 
 Disease progression,  
 Intercurrent illness that prevents further administration of treatment, 
 Unacceptable adverse event(s), 
 Patient decides to withdraw from the study, or 
 General or specific changes in the patient's condition render the patient 
unacceptable for further treatment in the judgment of the investigator. 
 
4.4  
After Protocol Therapy 
 
Patients enrolled in Arm A are encouraged to receive commercial single agent 
Tarceva® (erlotinib) in the extended study (Appendix J) after they failed single agent 
Alimta® (pemetrexed). Patients enrolled in Arm B may go on to receive further 


 
17
treatment at the discretion of the treating physician once they are discontinued from 
the study drugs. 
 
5. DOSING DELAYS/DOSE MODIFICATIONS 
 
5.1    General 
 
Dose adjustment at the starting of a subsequent cycle should be based on nadir 
hematological counts or maximum non-hematologic toxicity from the preceding cycle of 
therapy. Treatment may be delayed up to 2 weeks to allow sufficient time for recovery. 
Upon recovery, patients will be considered for dose reduction as below: 
 
Treatment should be discontinued if a patient experiences any hematological or non-
hematologic grade 3 or 4 toxicity after 2 dose reductions or immediately if grade 3 or 4 
neurotoxicity is observed.  
 
5.2 Pemetrexed Dose Modification/Toxicity Management 
Pemetrexed should not be administered to patients whose creatinine clearance is <45 
mL/min using the standard Cockcroft and Gault formulation or the measured glomerular 
filtration rate (GFR) using the appropriate radiolabeled method (51-CrEDTA or Tc99m-
DTPA) must be used to calculate CrCl for enrollment or dosing.  The same method used 
at baseline should be used throughout the study. No dose reduction is recommended for 
patients whose creatinine clearance is ≥ 45 mL/min. Insufficient numbers of patients have 
been studied with creatinine clearance <45 mL/min to give a dose recommendation. 
Therefore, Alimta should not be administered to patients whose calculated creatinine 
clearance is <45 mL/min.  
 
Caution should be exercised when administering pemetrexed concurrently with NSAIDs 
to patients whose creatinine clearance is <80 mL/min. 
 
            Table 2. Dose Reduction of Pemetrexed for Hematologic Toxicities 
 
Pemetrexed  
Dose Reduction 
Nadir ANC < 500/mm3 and nadir 
platelets ≥ 50, 000/mm3 
Given 75% of previous dose 
(maximal 2 reductions) 
nadir platelets < 50, 000/mm3 
regardless of nadir ANC 
Given 50% of previous dose 
(maximal 2 reductions) 
 
Table 3. Dose Reduction of Pemetrexed for Non-hematologic Toxicities 
NCI CTC Grade¹ 
Pemetrexed  
Dose Reduction 
Any grade 3 or 4 toxicities 
(including rash) except 
mucositis or neurotoxicity 
Given 75% of previous dose 
(maximal 2 reductions) 
Any diarrhea requiring 
hospitalization (irrespective of 
grade) or grade 3 or 4 diarrhea 
Given 75% of previous dose 
(maximal 2 reductions) 
Grade 3 or 4 mucositis 
Given 50% of previous dose 
(maximal 2 reductions) 


 
18
Grade 2 neurotoxicity 
Given 100% of previous dose 
 
 
 
¹NCI CTC Grade, National Cancer Institute Common Toxicity Criteria 
 
Therapy for Diarrhea: In the event of CTC Grade 3 or 4 diarrhea, the following 
supportive measures are allowed:  hydration, octreotide, and antidiarrheals. If diarrhea is 
severe (requiring intravenous rehydration) and/or associated with fever or severe 
neutropenia (Grade 3 or 4), broad-spectrum antibiotics must be prescribed.  Patients with 
severe diarrhea or any diarrhea associated with severe nausea or vomiting must be treated 
in the clinic or hospitalized for intravenous hydration and correction of electrolyte 
imbalances.  
 
5.3 Erlotinib Dose Modification/Toxicity Management 
5.3.1 Erlotinib Dose Modification 
If a patient has tolerated the treatment without any significant toxicity and have stable 
disease after 2 cycles of treatment, erlotinib dose could be escalated by 50 mg one or 
twice to a maximal dose of 250 mg with less than grade 2 toxicities in the combination at 
the discrepancy of treating physician (Table 4a).  
 
If a patient experiences several toxicities, dose adjustments are to be made based on the 
greatest degree of toxicity (ie, reducing the dose to the lowest level).  If significant 
toxicity is still apparent, the dose may be reduced a second time (Table 4b).  Any patient 
who fails to tolerate treatment of 50 mg/day will be withdrawn from the study. 
 
Table 4a. Dose Escalation for Erlotinib 
Dose Level 
Erlotinib  (Tarceva®) 
First dose escalation (+1 level) 
200 mg PO QD  
Second dose escalation (+2 level) 
250 mg PO QD 
Third dose escalation (+3 level) 
300 mg PO QD 
 
Table 4b. Dose Reduction for Erlotinib 
Dose Level 
Erlotinib  (Tarceva®) 
Starting dose 
150 mg PO QD  
First dose reduction 
100 mg PO QD 
Second dose reduction 
50 mg PO QD 
 
 
5.3.2 Erlotinib Dose Modification/Toxicity Management 
 
Antidiarrheal and antirash medications may be introduced if clinically indicated.  
Previous phase 1 and 2 studies have demonstrated that the frequency and severity of 
diarrhea can be managed with loperamide.  The recommended dose of loperamide is 
4 mg at first onset, followed by 2 mg every 2 to 4 hours until diarrhea resolves for 
12 hours.  
 
In the event of severe or persistent diarrhea, nausea, anorexia, or vomiting associated 
with dehydration, erlotinib therapy should be interrupted and appropriate measures 
should be taken to intensively treat the dehydration.  Since there have been rare reports of 


 
19
hypokalemia and/or acute renal failure (including fatalities), secondary to severe 
dehydration, renal function and serum electrolytes (including potassium) should be 
monitored in this setting. 
 
Patients should be informed that skin toxicity is to be expected during treatment with 
erlotinib.  Skin toxicity may take the form of dry skin, rash, acneiform eruption, or hair or 
nail changes.  Prophylactic treatment of the skin may prevent or reduce skin toxicity.  
The patient should be encouraged to use an alcohol-free, emollient cream applied twice a 
day to the entire body as soon as the patient starts therapy with erlotinib.  Creams and 
ointments are recommended because they have a greater ability to retain moisture than 
lotions.  Examples of suitable emollient creams include:  Neutrogena® Norwegian 
formula, SARNA® Ultra, Vanicream™, Aveeno® (fragrance-free formulation), and 
Eucerin® cream.  Other over-the-counter aqueous creams or emulsifying ointments may 
also provide symptomatic benefit.  Lotions should be avoided because they often contain 
alcohol, which will dry the skin.  Patients should also be encouraged to use a titanium 
dioxide or zinc oxide-based sunscreen product applied to sun-exposed areas twice per 
day. 
 
Patients who develop skin toxicity and are symptomatic should be treated with topical 
therapy such as hydrocortisone cream or clindamycin gel.  If needed, oral minocycline or 
oral doxycycline may be combined with the topical therapy.  A topical immodulating 
cream such as Elidel could also be considered.  For more severe rash, oral corticosteroids 
may be beneficial.  Patients who fail to respond to these measures may have the dose of 
erlotinib interrupted or reduced.   
 
Minocycline is known to interfere with anticoagulants and oral contraceptives.  Patients 
treated with minocycline who are taking anticoagulants and/or oral contraceptives should 
be monitored accordingly. 
 
There have been infrequent reports of serious ILD, including fatal events, in patients 
receiving erlotinib for the treatment of NSCLC and other advanced solid tumors.  In the 
event of acute onset of new or progressive, unexplained pulmonary symptoms such as 
dyspnea, cough, and fever, study drug should be interrupted pending diagnostic 
evaluation.  If ILD is diagnosed, study drug should be permanently discontinued and 
appropriate treatment instituted as necessary. 
 
Erlotinib dosing should be discontinued for any severe toxicity that does not respond to 
treatment or failure to recover within 14 days from hematological toxicity attributable to 
Tarceva. 
 
Management of other non-hematologic toxicity, therapy should be held until resolution to 
Grade 2 or less; for Grade 3 non-hematologic toxicities with a 50mg dose reduction when 
therapy is reinstituted. Patients experiencing a Grade 4 non-hematologic toxicity should 
have therapy discontinued. 
 
 


 
20
Table 5. Dose Reduction Criteria for Erlotinib-related Toxicities 
Toxicity 
(NCI CTCAE v3.0) 
Dose Modificationa 
Diarrhea 
Grade 1 or 2 
None.  Initiate therapy with loperamide. 
Grade 3bor 4b 
Interrupt erlotinib until resolution to < grade 2 and then restart 1 dose 
level lower. 
Rash 
Grade 1 
None 
Grade 2 
None.  Initiate treatment as outlined in Section 5.3.  If rash persists 
and is intolerable or worsens over 10 – 14 days, then reduce by 1 dose 
level.  
Grade 3b 
Reduce by 1 dose level.  If rash persists or worsens over 10 – 14 days, 
then interrupt Tarceva® until resolution to < grade 2 and then restart 
1 dose level lower. 
Grade 4 
Permanently discontinue erlotinib. 
       Interstitial Lung Disease 
Any Grade 
If ILD is suspected, Tarceva® should be interrupted immediately  
pending diagnostic evaluation.  If ILD is diagnosed, Tarceva® should 
be discontinued permanently and appropriate treatment instituted as 
necessary. 
Other Non-hematological Toxicities 
Grade 1 or 2 
None 
Grade 3b, c 
Interrupt erlotinib until resolution to < grade 2 within 14 days and 
then restart 1 dose level lower. 
Grade 4 
Permanently discontinue erlotinib 
a) Doses that have been reduced 1 dose level for toxicity may be re-escalated to the previous 
dose level only if the toxicity abates or returns to baseline severity and the investigator 
believes it is in the best interest of the patient.  Doses that have been reduced 2 dose levels 
for toxicity may only be re-escalated to the previous dose level (i.e., dose level at first 
reduction) and only if the toxicity abates or returns to baseline severity and the investigator 
believes it is in the best interest of the patient.  Doses that have been reduced 2 or more dose 
levels for toxicity may not be re-escalated to the starting dose level (or dose-escalated dose 
for tobacco smokers).  Any patient who fails to tolerate treatment at 50 mg/day will be 
discontinued from the study. 
b) If the event does not resolve to  grade 2 within 14 days, erlotinib will be discontinued. 
c) Only if  2 grade level change from baseline 
 
 
6.  
PHARMACEUTICAL INFORMATION 
 
6.1 
Pemetrexed disodium heptahydrate (Alimta)  
  
Chemical Name:  Pemetrexed disodium heptahydrate has the chemical name L-Glutamic 
acid, 
N-[4-[2-(2-amino-4,7-dihydro-4-oxo-1H-pyrrolo[2,3-d]pyrimidin-5-yl)ethyl] 
benzoyl] -, disodium salt, heptahydrate. The structural formula is as follows: 


 
21
 
 
 
Classification:  an antifolate antineoplastic agent. 
 
Molecular Formula: C20H19N5Na2O6•7H2O  
Molecular Weight: 597.49 
 
Mode of Action: 
Pemetrexed is an antifolate antineoplastic agent that exerts its action by disrupting folate-
dependent metabolic processes essential for cell replication. 
 
How Supplied:  
ALIMTA is supplied as a sterile lyophilized powder for intravenous infusion available 
in single-dose vials. The product is a white to either light yellow or green-yellow 
lyophilized solid. Each 500-mg vial of ALIMTA contains pemetrexed disodium 
equivalent to 500 mg pemetrexed and 500 mg of mannitol. Hydrochloric acid and/or 
sodium hydroxide may have been added to adjust pH. 
 
NDC 0002-7623-01 (VL7623): single-use vial with flip-off cap individually packaged in 
a carton. 
 
Storage: 
ALIMTA, pemetrexed for injection, should be stored at 25C (77F); excursions 
permitted to 15-30C (59-86F) [see USP Controlled Room Temperature]. Chemical and 
physical stability of reconstituted and infusion solutions of ALIMTA were 
demonstrated for up to 24 hours following initial reconstitution, when stored refrigerated, 
2-8C (36-46F), or at 25 C (77F), excursions permitted to 15-30C (59-86F) [see 
USP Controlled Room Temperature]. When prepared as directed, reconstituted and 
infusion solutions of ALIMTA contain no antimicrobial preservatives. Discard unused 
portion. ALIMTA is not light sensitive. 
 
Route of Administration:  injection 
 
Preparation for Intravenous Infusion Administration: 
1. Use aseptic technique during the reconstitution and further dilution of ALIMTA for 
intravenous infusion administration. 
2. Calculate the dose and the number of ALIMTA vials needed. Each vial contains 500 
mg of ALIMTA. The vial contains an excess of ALIMTA to facilitate delivery of label 
amount. 
3. Reconstitute 500-mg vials with 20 mL of 0.9% Sodium Chloride Injection 
(preservative free) to give a solution containing 25 mg/mL ALIMTA. Gently swirl each 


 
22
vial until the powder is completely dissolved. The resulting solution is clear and ranges in 
color from colorless to yellow or green-yellow without adversely affecting product 
quality. The pH of the reconstituted ALIMTA solution is between 6.6 and 7.8. 
FURTHER DILUTION IS REQUIRED. 
4. Parenteral drug products should be inspected visually for particulate matter and 
discoloration prior to administration. If particulate matter is observed, do not administer.  
5. The appropriate volume of reconstituted ALIMTA solution should be further diluted 
to 100 mL with 0.9% Sodium Chloride Injection (preservative free) and administered as 
an intravenous infusion over 10 minutes. 
6. Chemical and physical stability of reconstituted and infusion solutions of ALIMTA 
were demonstrated for up to 24 hours following initial reconstitution, when stored at 
refrigerated or ambient room temperature [see USP Controlled Room Temperature] and 
lighting. When prepared as directed, reconstitution and infusion solutions of ALIMTA 
contain no antimicrobial preservatives. Discard any unused portion. Reconstitution and 
further dilution prior to intravenous infusion is only recommended with 0.9% Sodium 
Chloride Injection (preservative free). ALIMTA is physically incompatible with 
diluents containing calcium, including Lactated Ringer’s Injection, USP and Ringer’s 
Injection, USP and therefore these should not be used. Co-administration of ALIMTA 
with other drugs and diluents has not been studied, and therefore is not recommended. 
 
Pharmacodynamics: 
Pemetrexed is an antifolate containing the pyrrolopyrimidine-based nucleus that exerts its 
antineoplastic activity by disrupting folate-dependent metabolic processes essential for 
cell replication. In vitro studies have shown that pemetrexed inhibits thymidylate 
synthase (TS), dihydrofolate reductase (DHFR), and glycinamide ribonucleotide 
formyltransferase (GARFT), all folate-dependent enzymes involved in the de novo 
biosynthesis of thymidine and purine nucleotides. Both the reduced folate carrier and 
membrane folate binding protein transport systems transport pemetrexed into cells. Once 
in the cell, pemetrexed is converted to polyglutamate forms by the enzyme 
folylpolyglutamate synthetase. The polyglutamate forms are retained in cells and are 
inhibitors of TS and GARFT. Polyglutamation is a time- and concentration-dependent 
process that occurs in tumor cells and, to a lesser extent, in normal tissues. 
Polyglutamated metabolites have an increased intracellular half-life resulting in 
prolonged drug action in malignant cells. 
 
Preclinical studies have shown that pemetrexed inhibits the in vitro growth of 
mesothelioma cell lines (MSTO-211H, NCI-H2052). Studies with the MSTO-211H 
mesothelioma cell line showed synergistic effects when pemetrexed was combined 
concurrently with cisplatin. Absolute neutrophil counts (ANC) following single-agent 
administration of pemetrexed to patients not receiving folic acid and vitamin B12 
supplementation were characterized using population pharmacodynamic analyses. 
Severity of hematologic toxicity, as measured by the depth of the ANC nadir, is inversely 
proportional to the systemic exposure of ALIMTA. It was also observed that lower 
ANC nadirs occurred in patients with elevated baseline cystathionine or homocysteine 
concentrations. The levels of these substances can be reduced by folic acid and vitamin 
B12 supplementation. There is no cumulative effect of pemetrexed exposure on ANC 
nadir over multiple treatment cycles. 
 


 
23
Pharmacokinetics: 
The pharmacokinetics of pemetrexed administered as a single agent in doses ranging 
from 0.2 to 838 mg/m2 infused over a 10-minute period have been evaluated in 426 
cancer patients with a variety of solid tumors. Pemetrexed is not metabolized to an 
appreciable extent and is primarily eliminated in the urine, with 70% to 90% of the dose 
recovered unchanged within the first 24 hours following administration. The total 
systemic clearance of pemetrexed is 91.8 mL/min and the elimination half-life of 
pemetrexed is 3.5 hours in patients with normal renal function (creatinine clearance of 90 
mL/min). The clearance decreases, and exposure (AUC) increases, as renal function 
decreases. Pemetrexed total systemic exposure (AUC) and maximum plasma 
concentration (Cmax) increase proportionally with dose.  
 
The pharmacokinetics of pemetrexed does not change over multiple treatment cycles. 
Pemetrexed has a steady-state volume of distribution of 16.1 liters. In vitro studies 
indicate that pemetrexed is approximately 81% bound to plasma proteins. Binding is not 
affected by degree of renal impairment. 
 
Potential Drug Interactions:  
Chemotherapeutic Agents — Cisplatin does not affect the pharmacokinetics of 
pemetrexed and the pharmacokinetics of total platinum is unaltered by pemetrexed. 
 
Vitamins — Coadministration of oral folic acid or intramuscular vitamin B12 does not 
affect the pharmacokinetics of pemetrexed. 
 
Drugs Metabolized by Cytochrome P450 Enzymes — Results from in vitro studies with 
human liver microsomes predict that pemetrexed would not cause clinically significant 
inhibition of metabolic clearance of drugs metabolized by CYP3A, CYP2D6, CYP2C9, 
and CYP1A2. No studies were conducted to determine the cytochrome P450 isozyme 
induction potential of pemetrexed, because ALIMTA used as recommended (once 
every 21 days) would not be expected to cause any significant enzyme induction. 
 
Aspirin — Aspirin, administered in low to moderate doses (325 mg every 6 hours), does 
not affect the pharmacokinetics of pemetrexed. The effect of greater doses of aspirin on 
pemetrexed pharmacokinetics is unknown. 
 
Ibuprofen — Daily ibuprofen doses of 400 mg qid reduce pemetrexed’s clearance by 
about 20% (and increase AUC by 20%) in patients with normal renal function. The effect 
of greater doses of ibuprofen on pemetrexed pharmacokinetics is unknown.  ALIMTA 
is primarily eliminated unchanged renally as a result of glomerular filtration and tubular 
secretion. Concomitant administration of nephrotoxic drugs could result in delayed 
clearance of ALIMTA. Concomitant administration of substances that are also 
tubularly secreted (e.g., probenecid) could potentially result in delayed clearance of 
ALIMTA. Although ibuprofen (400 mg qid) can be administered with ALIMTA in 
patients with normal renal function (creatinine clearance 80 mL/min), caution should be 
used when administering ibuprofen concurrently with ALIMTA to patients with mild to 
moderate renal insufficiency (creatinine clearance from 45 to 79 mL/min). Patients with 
mild to moderate renal insufficiency should avoid taking NSAIDs with short elimination 
half-lives for a period of 2 days before, the day of, and 2 days following administration of 


 
24
ALIMTA. In the absence of data regarding potential interaction between ALIMTA 
and NSAIDs with longer half-lives, all patients taking these NSAIDs should interrupt 
dosing for at least 5 days before, the day of, and 2 days following ALIMTA 
administration. If concomitant administration of an NSAID is necessary, patients should 
be monitored closely for toxicity, especially myelosuppression, renal, and gastrointestinal 
toxicity. 
 
Special Populations: 
The pharmacokinetics of pemetrexed in special populations was examined in about 400 
patients in controlled and single arm studies. 
Geriatric — No effect of age on the pharmacokinetics of pemetrexed was observed over a 
range of 26 to 80 years. 
Pediatric — Pediatric patients were not included in clinical trials. 
Gender — The pharmacokinetics of pemetrexed were not different in male and female 
patients. 
Race — The pharmacokinetics of pemetrexed were similar in Caucasians and patients of 
African descent. Insufficient data are available to compare pharmacokinetics for other 
ethnic groups. 
Hepatic Insufficiency —There was no effect of elevated AST (SGOT), ALT (SGPT), or 
total bilirubin on the pharmacokinetics of pemetrexed. However, studies of hepatically 
impaired patients have not been conducted. 
Renal Insufficiency — Pharmacokinetic analyses of pemetrexed included 127 patients 
with reduced renal function. Plasma clearance of pemetrexed in the presence of cisplatin 
decreases as renal function decreases, with increase in systemic exposure. Patients with 
creatinine clearances of 45, 50, and 80 mL/min had 65%, 54%, and 13% increases, 
respectively, in pemetrexed total systemic exposure (AUC) compared to patients with 
creatinine clearance of 100 mL/min. 
 
Carcinogenesis, Mutagenesis, Impairment of Fertility 
No carcinogenicity studies have been conducted with pemetrexed. Pemetrexed was 
clastogenic in the in vivo micronucleus assay in mouse bone marrow but was not 
mutagenic in multiple in vitro tests (Ames assay, CHO cell assay). Pemetrexed 
administered at i.v. doses of 0.1 mg/kg/day or greater to male mice (about 1/1666 the 
recommended human dose on a mg/m2 basis) resulted in reduced fertility, hypospermia, 
and testicular atrophy. 
 
Pregnancy  
Category D. 
 
Nursing Mothers 
It is not known whether ALIMTA or its metabolites are excreted in human milk. 
Because many drugs are excreted in human milk, and because of the potential for serious 
adverse reactions in nursing infants from ALIMTA, it is recommended that nursing be 
discontinued if the mother is treated with ALIMTA. 
 
Availability: 


 
25
Alimta (Pemetrexed) is commercially available and is approved for this indication. 
Alimta (Pemetrexed) is distributed by Eli Lilly (Indianapolis, IN). Pemetrexed will be 
provided by Eli Lilly free of charge. 
 
Expected adverse events:   
Hematologic: Anemia (17%), Leukopenia/neutropenia (11.9%), lymphopenia (2.7%), 
Thrombocytopenia 
(8.3%), 
Febrile 
neutropenia 
(1.7%), 
Leukocytosis 
(0.8%), 
Lymphadenopathy (0.4%), Pancytopenia (0.4%), Coagulopathy (0.2%), Lymph node 
pain (0.2%) 
 
Cardiac Disorders: Tachycardia (2.3%), Palpitations (1%), Cardiac failure (0.8%), 
Myocardial infarction (0.8%), Atrial fibrillation (0.6%), Congestive heart failure (0.6%), 
Pericardial effusion (0.6%), Coronary artery disease/angina pectoris (0.4%), Acute 
myocardial infarction/unstable angina//myocardial ischemia (0.2%), Arrhythmia (0.2%), 
Cardiac arrest (0.2%), Cardio-respiratory arrest/failure (0.2%)  
 
Pulmonary/Thoracic: Dyspnea (22%), Epistaxis (2.3%), Hiccups (1.7%), Cough 
(18.5%), Hoarseness (1.9%), Pleural effusion (2.3%), Hypoxia (0.8%), Respiratory 
failure (0.8%), Pulmonary edema (0.6%), Pulmonary embolism (0.6%), Pneumothorax 
(0.4%), Acute respiratory distress syndrome (0.2%), Pneumonitis (1%)/interstitial lung 
disease (0.2%), Respiratory tract hemorrhage (0.2%), Sinus congestion (1.2%), 
emphysema (0.2%), asthma (0.2%), Respiratory arrest (0.2%) 
 
Gastrointestinal Disorders: Nausea (39.7%), Vomiting (24.3%), Abnormal liver tests 
(increased ALT (26.6%)/increased AST (12.9%)), Diarrhea (21.2%), Constipation 
(19.3%), Stomatitis (7.9%), Abdominal pain (7.7%), dyspepsia (4.8%), Dysphagia 
(1.7%), Odynophagia (0.4%), 
Esophageal ulcer (0.4%), Esophagitis 
(0.2%), 
Gastrointestinal bleeding (0.2%), Ascites (0.4%), Cheilitis (0.4%), Discolored feces 
(0.4%), Ileus (0.4%), Enterocolitis (0.2%)/stomach or bowel irritation (which may cause 
ulcer or fistula) (0.2%), Diverticulum (0.2%), Intestinal obstruction/intussusception 
(0.2%), Glossitis (0.2%), Hepatic failure (0.6%), Hepatomegaly (0.4%), Hepatotoxicity 
(0.4%), Jaundice (0.4%), Cholecystitis (0.2%), Hepatitis (0.2%) 
Renal and Urinary Disorders: Dysuria (2.1%), Renal insufficiency (0.8%), 
Hematuria/pyuria (0.4%), Toxic nephropathy (0.2%), Acute renal failure (0.4%), 
Hydronephrosis (0.6%), Renal pain (0.8%) 
 
Immune System Disorders: Allergic Reaction/Drug Hypersensitivity (<1%) 
 
Infections: Pneumonia (5.4%), Urinary tract infection (5%), Infection (3.7%), 
Naso/pharyngitis (2.7%), Herpes zoster (1.9%), Bronchitis/sinusitis (1.5%), Cellulitis 
(1%), Candidiasis (0.6%), Wound infection (0.6%), Sepsis (0.4%)/sepsis syndrome 
(0.2%), Erysipelas (0.2%), Eye infection (0.2%), Catheter related infection (0.2%), 
Diverticulitis (0.2%) 
 
Metabolism and Nutrition Disorders: Anorexia (26%), Dehydration (4.6%), 
Electrolyte abnormalities (1 to 3%), Diabetes mellitus (0.6%), Hypoalbuminemia (1.3%), 
Metabolic acidosis (0.4%), Vitamin B12 deficiency (0.2%) 
 


 
26
Skin: Rash (13.5%), Alopecia (7.9%), Pruritus (6.7%) Pigmentation disorder (1%), Face 
edema (1.5%), Dry Skin (1%), Nail disorder (0.4%), Photosensitivity reaction (0.4%), 
Toxic skin eruption (0.4%), Erythema multiforme (0.2%), Night sweats (1.5%), Skin 
discoloration (0.4%) 
 
Psychiatric: Insomnia (9.4%), Anxiety (4.0%), Depression (4.8%), Confusional state 
(2.1%), Depressed mood (0.8%), Hallucination (0.8%), Suicidal ideation (0.2%) 
 
Endocrine Disorders: Adrenal insufficiency (0.2%), Cushingoid (0.2%), Thyroiditis 
(0.2%) 
 
Eye Disorders: Increased lacrimation (4.4%), Conjunctivitis (3.1%), Vision blurred 
(1.7%), visual disturbance (0.2%), Eye irritation (0.8%), Keratoconjunctivitis sicca 
(1.3%), Keratitis (0.2%), Cataract (0.8 %), Blindness (0.6%), Blepharitis (0.6%), eye 
pain/eyelid edema (0.4%), Retinal artery occlusion (0.2%) 
 
Nervous System Disorders: Dizziness (8.7%), Headache (11.2%), Dysgeusia (2.1%), 
Neuropathy (3.9%), Paresthesias (13.5%), Sciatica (0.6%), Amnesia (0.6%), Cognitive 
disorder (0.4%), Neurotoxicity (0.4%), Somnolence (1.2%), Ataxia (0.6%), Balance 
Disorder (0.2%), Dysarthria (0.6%), Depressed level of consciousness (1.2%), Syncope 
(0.6%), Tremor (1.3%), Grand mal convulsion (0.2%), Brain edema (0.2%), Carotid 
artery occlusion (0.2%), Cerebellar syndrome (0.2%), Cerebrovascular accident (0.2%), 
Spinal cord compression (0.2%) 
 
Ear and Labyrinth: Deafness (0.4%), Hypo/hyperacusis (0.2%), Vertigo (1.9%), 
hearing impaired (0.2%), ear pain (0.2%)  
 
Musculoskeletal: Myalgia (6.2%), Back pain (6.4%) Arthralgia (8.1%), Bone pain 
(4.8%), Joint swelling (0.4%), Muscular weakness (1%), muscle spasms (0.6%), 
Osteopenia (0.2%)  
 
Vascular Disorders: Flushing (2.5%), Hypotension (1.5%), Hypertension (1%), 
Phlebitis (0.4%), Deep vein thrombosis (0.4%), Angiopathy (0.4%), Hemorrhage (0.2%), 
Circulatory collapse (0.2%), Superior vena caval occlusion (0.2%), Vasculitis (0.2%), 
Orthostatic hypotension (0.2%) 
 
Neoplasm: Cancer pain (2.1%), Rare (all <1%): Malignant pleural effusion, Tumor 
associated fever, Oral neoplasm, breast cancer, fibroma, lymphangiosis carcinomatosa, 
thyroid neoplasm, vulval neoplasm, and Tumor hemorrhage  
 
Reproductive System: Breast pain (0.8%), Vaginal pruritus (0.6%)/pain (0.2%), Pelvic 
pain (0.4%), Scrotal edema /testicular pain (0.2%), Erectile dysfunction (0.2%) 
 
General Disorders and Administration Site Conditions: Fatigue (38.9%%), Asthenia 
12.7%), Pyrexia (22.5%), Mucosal inflammation (6.9%), Rigors (5.6%), Peripheral 
edema (6.7%), Malaise (1.9%), Chest pain (9.6%), Flu like illness (0.4%), Pain (7.1%%), 
Abnormal gait (0.6%), General physical health deterioration (1.3%), Injection site 
reaction (0.2%), Generalized/Localized edema (<1%), Thirst (0.2%), Feeling 


 
27
hot/cold/jittery (0.2%), Drug withdrawal syndrome (0.2%) 
 
Please refer to package insert for further information on Alimta (Pemetrexed). 
 
 
References: www.ALIMTA.com; Alimta Clinical Investigator’s Brochure, version April 
29, 2005. Updated version: July 27, 2006, and May 23, 2008. 
 
6.2 
Erlotinib (Tarceva®) 
Chemical Name: Erlotinib is a quinazolinamine with the chemical name N-(3-
ethynylphenyl)-6,7-bis(2-methoxyethoxy)-4-quinazolinamine. 
TARCEVA 
contains 
erlotinib as the hydrochloride salt, which has the following structural formula: 
 
 
Other Names: CP-358, 774, USAN: OSI-774 (Erlotinib) hydrochloride, Tarceva®  
 
Classification:  Signal Transduction Inhibitor, Tyrosine kinase Inhibitor (EGFR) 
 
Molecular Formula: C22H23N3O4.HCl  
Molecular Weight: 429.90 
 
Mode of Action:  
The mechanism of clinical anti-tumor action of erlotinib is not fully characterized. 
Erlotinib inhibits the intracellular phosphorylation of tyrosine kinase associated with the 
epidermal growth factor receptor (EGFR). Specificity of inhibition with regard to other 
tyrosine kinase receptors has not been fully characterized. EGFR is expressed on the cell 
surface of normal cells and cancer cells. 
 
How Supplied:  
Erlotinib tablets are available in 25 mg, 100 mg and 150 mg erlotinib and contain the 
following inactive ingredients: lactose monohydrate, hypromellose, hydroxypropyl 
cellulose, magnesium stearate, microcrystalline cellulose, sodium starch glycolate, 
sodium lauryl sulfate and titanium dioxide.    All tablets are round, white, film-coated bi-
convex tablets without markings.  Tarceva® (erlotinib hydrochloride) will be supplied by 
OSI Pharmaceuticals, Inc., Melville, NY. 
 
Storage:  
The intact bottles should be stored at controlled room temperature15°C-30°C- (59°F and 
86°F).  Tarceva® tablets are supplied in blue-white high-density polyethylene (HDPE) 
bottles of 30 each with some overage.  
 
Route of Administration:  Oral. 
 


 
28
Method of Administration 
Tarceva® tablets should be taken at approximately the same time each day.  Each 
Tarceva® dose is to be taken with up to 200 mL (~ 1 cup or 8 oz) of water one hour 
before or two hours after meals or medications, including vitamins and iron supplements.  
Tarceva® should not be taken with grapefruit juice.  The entire dose must be taken at one 
time.  If the patient vomits after taking the tablet(s), the dose is replaced only if the 
tablet(s) can actually be seen and counted. 
• Administration through G-tube: The tablets required for the dose should be dissolved in 
100 mL of sterile water. The dissolved tablets should be shaken vigorously to form a 
uniform suspension. The suspension should be drawn up into a syringe and administered 
through the G-tube port. Repeat the syringe transfer until the entire volume has been 
administered. A small volume (40 mL) of sterile water should be added to the container 
used to dissolve the tablets and the residual suspension should be shaken, aspirated into 
syringe, and administered. This last step should be repeated to ensure the entire dose is 
administered. The total volume of delivery/rinse (as per procedure submitted to IND) is 
~180 ml. 
 
Formulation 
OSI-774 is an off-white to pale yellow powder. The pharmaceutical preparations of OSI-
774 are formulations containing the hydrochloride salt (OSI-774-01). In addition to the 
active ingredient, erlotinib tablets contain lactose (hydrous), microcrystalline cellulose, 
sodium starch glycolate, sodium lauryl sulfate, and magnesium stearate. Initial clinical 
studies with OSI-774 used both a tablet and an oral powder for constitution (OPC) in 
water.  Study drug for daily oral administration will be supplied as 25mg, 100mg and 
150mg tablets in separate bottles, containing 30 tablets with some overage.    
 
Expected adverse events: The side effects of Tarceva® may include but are not limited to: 
Common (occur in more than 20% of patients): 
 
Skin rash 
 
Diarrhea (this may be treated with anti-diarrhea drugs) 
 
Loss of appetite 
 
Tiredness or fatigue 
 
New or worse shortness of breath 
 
Cough 
 
Nausea 
 
Vomiting 
 
Infections 
 
Itching 
 
Weight loss 
 
Dry skin 
 
Less Common (occur in 5%-20% of patients): 
 
Dehydration (loss of too much body fluid) 
 
Dry, red, irritated eyes 
 
Abdominal or stomach pain 
 
Depression 
 
Gas, heartburn or upset stomach 
 
Headache 
 
Neuropathy (nerve damaging resulting in numbness or tingling) 


 
29
 
Chills or shakes 
 
Chest pain 
 
Nose bleeds 
 
Coughing up blood 
 
Hair loss or thinning 
 
Dry mouth 
 
Fever 
 
Mouth sores or mouth ulcers 
 
Constipation 
 
Rare (occur in less than 5% of patients): 
 
Change sin liver function tests which may indicated liver damage; isolated reports of 
liver failure 
 
Damage to the front eye, which may lead to changes in vision. 
 
Irritation of stomach or bowel which may lead to ulcers (lining breakdown) or 
bleeding 
 
ILD (Interstitial Lung Disease).  An irritation of the lungs, which rarely may be 
severe, and life threatening. 
 
Decreased liver function; isolated reports of kidney failure 
 
Changes in the sense of taste 
 
Severe infections which may be life threatening 
 
Increased risk of bleeding in patients who have low platelet count, are taking blood 
thinners, or are taking certain drugs for pain called NSAIDs such as aspirin or 
ibuprofen 
 
Fingernail/toenail changes and/or irritation of skin around nails 
 
Possible cracking of skin, especially of finger and toes 
 
Isolated reports of increased body hair growth or eyelash/eyebrow changes 
 
 
Incompatibilities / Potential Drug Interactions 
Tarceva® is both protein bound (92% to 95% in humans) and metabolized in the liver by 
CYP3A4 and, to a lesser extent, CYP1A2, and in the lungs by CYP1A1.  A potential for 
drug-drug interaction exists when Tarceva® is co-administered with drugs that are highly 
protein bound or that are CYP3A4 and CYP1A2 inhibitors/inducers. 
 
For patients who are being concomitantly treated with a potent CYP3A4 inhibitor, a dose 
reduction should be considered in the presence of severe adverse events.  For patients 
who are being concomitantly treated with a potent CYP3A4 inducer, alternative 
treatments that lack potent CYP3A4-inducing properties should be considered. 
 
Tarceva® clearance can be induced by smoking via CYP1A2 induction.  Smokers should 
be advised to stop smoking while taking Tarceva®, as plasma concentrations of 
Tarceva® are reduced due to the effect of cigarette smoking. 
 
Grapefruit juice is a CYP3A4 inhibitor that interferes with the metabolism of Tarceva®.  
Therefore, consumption of grapefruit or grapefruit juice should be avoided during 
Tarceva® treatment. 
 
In addition, altered coagulation parameters and bleeding have been reported in patients 
receiving Tarceva® alone and in combination with other chemotherapeutic agents and 


 
30
concomitant warfarin-derivative anticoagulants.  The mechanism for these alterations is 
still unknown.  When warfarin is coadministered with Tarceva® (anytime after Day 5), 
international normalized ratio (INR), and prothrombin time should be closely monitored 
and the anticoagulant dose should be adjusted as clinically indicated. 
Pregnancy  Category D.  
Nursing Mothers It is not known whether erlotinib is excreted in human milk. Because 
many drugs are excreted in human milk and because the effects of TARCEVA® on 
infants have not been studied, women should be advised against breast-feeding while 
receiving TARCEVA® therapy. 
Pediatric Use The safety and effectiveness of TARCEVA® in pediatric patients have not 
been studied. 
Geriatric Use Of the total number of patients participating in the randomized trial, 62% 
were less than 65 years of age, and 38% of patients were aged 65 years or older. The 
survival benefit was maintained across both age groups. No meaningful differences in 
safety or pharmacokinetics were observed between younger and older patients. Therefore, 
no dosage adjustments are recommended in elderly patients.  
Patient Implications 
Patients should be instructed to avoid grapefruit juice for the duration of the study. 
Special caution should be taken for patients taking warfarin.   
 
Availability: 
Tarceva (Erlotinib) is commercially available and is approved for this indication. 
Tarceva (Erlotinib) is marketed by both Genentech BioOncology and OSI 
Pharmaceuticals and is supplied by OSI Pharmaceuticals.  Patients in Arm B (concomitant 
arm) will take Tarceva (erlotinib) orally as instructed. OSI Pharmaceuticals is supplying 
Tarceva (Erlotinib) free of charge for all patients on Arm B. 
 
 
References 
Investigator’s Brochure: OSI 774 (Erlotinib, Tarceva®) OSI Pharmaceuticals, February 
15, 2007. 
 
7. 
CORRELATIVE STUDIES 
 
Informed consent (Appendix A) must be signed prior to obtaining and/or submission of 
any materials for the laboratory correlative studies.  
 
7.1  
Statement of Hypotheses and Objectives: 
 
As reviewed in previous sections, less than 10% of patients with advanced NSCLC in the 
United States have objective response to monotherapy of erlotinib or pemetrexed. Correlative 
studies to select the subgroup of patients that might benefit from erlotinib and/or pemetrexed in 
advanced NSCLC, a disease in which clinical benefit of these agents has been demonstrated, are 
demanded.  
 
 
Based on the literature and our preliminary data, we hypothesize that: 


 
31
1) The mutations in the K-Ras and/or p53 genes correlate with a history of >15 PY of 
smoking and clinical resistance to erlotinib and/or pemetrexed; while the mutations in the 
EGFR and caveolin-1 genes (that are related to non-smoking or light smoking) will 
correlate with a history of ≤ 15 PY of smoking and clinical sensitivity to erlotinib and/or 
pemetrexed.  
2) High gene copy number of EGFR in NSCLC tumors correlates with more dependent of 
these tumor cells on the EGFR signaling transduction pathway for tumor growth and 
survival, and thus clinical sensitivity to erlotinib and/or pemetrexed.  
3) Effective inhibition of active EGFR axis (i.e., p-EGFR and activated down-stream 
effectors) and/or folate-dependent tumor metabolism (TS and associated drug metabolism 
genes) correlate with increased clinical benefit from erlotinib and/or pemetrexed 
respectively.  
4) The expression of Epithelial to Mesenchymal Transition (EMT) Markers and sensitivity to 
erlotinib. 
5) The presence of ≥ grade 2 skin changes is associated with erlotinib-associated inhibition of 
pEGFR and immune and inflammatory changes in the skin, which correlate with clinical 
response and patient survival to erlotinib and/or pemetrexed.  
6) Patients who develop significant skin rashes have more competent T-cell mediated 
immunity that correlate with better clinical outcome.  
 
The overall objective of the correlative studies is to determine several molecular and cellular 
biomarkers in the tumors and the skin that are predictive for the clinical efficacy of pemetrexed 
and erlotinib. More specifically,  
7.1.1 To determine the presence of known “hot spot” mutations in genomic DNA in the 
intracellular tyrosine kinase domain of EGFR gene, exon 2 of K-Ras gene, exons 5-8 of 
p53 and the transmembrane domain of caveolin-1 gene, and to determine their 
correlation with smoking and with clinical response to erlotinib and/or pemetrexed. 
7.1.2 To determine pre-treatment gene copy number of EGFR gene and to determine its 
association with clinical benefit of erlotinib with or without pemetrexed.  
7.1.3 To determine the altered protein expression in the EGFR signaling axis and folate-
dependent target/metabolism axis [i.e., p-EGFR, p-AKT, p-MAPK, p-STAT, p27, 
cyclin D1, E-cadherin, vimentin, fibronectin, thymidylate synthase (TS), reduced folate 
carrier (RFC), folate receptor, folypolyglutamate synthetase (FPGS), glutamyl 
hydrolase (GH)] by immunohistochemistry (IHC) and to determine the correlation of 
these changes to clinical efficacy and survival.  
7.1.4 To determine the presence of ≥ grade 2 skin changes is associated with inhibition of 
pEGFR and erlotinib-associated immune and inflammatory changes (i.e., cytotoxic T 
cells, macrophage, interferon γ, IL-10, TGF beta) in the skin, which correlate with 
clinical response and patient survival in relation to erlotinib and/or pemetrexed. 
7.1.5 To determine if the status of host T cell immunity and its relationship to the presence of 
skin rash and clinical outcome.   
 
7.2   Background and Rationale (see section 2.5).  
 
 
7.3 Tissue Requirements and Assays 
Although high throughput techniques like microarray and proteomics will allow 
simultaneous determination of up to thousands of genes and proteins in patients before and after 
the treatment, it is limited by the need for large amounts of tumor tissues and labored collection. 


 
32
Thus, we will focus on several biomarkers suggested by our and others preclinical studies for 
erlotinib or pemetrexed to predict their clinical response and benefit, and only performed array-
based genomic analysis and proteomics in selected patients when rebiopsy of the tumor is done.  
 
7.3.1  Tissue requirements: 
Tumor samples: We will put all efforts to obtain at least the diagnostic tissue blocks for the 
correlative studies. Tumor tissues will be available from the diagnostic biopsy. Pre- and post-
treatment tumor biopsies will be obtained if there are accessible tumors by CT-guided biopsy or 
brush and wash samples by bronchoscopy with patient’s consent. From our previous experience, 
2-3 core biopsies usually contain enough tumors for further analyses. Tumor cells from 
malignant pleural effusion have also been reported as a good source for correlative studies [76]. 
The tumors will be embedded in OCT solution or snap frozen in a liquid nitrogen bath. Aliquots 
of tumors will be fixed in formalin and embedded in paraffin.  
 
Skin samples: Serial 3mm-punch skin biopsies under local anesthesia on the back of upper 
torso are minimal invasive and can be done within 20 minutes during an outpatient visit. This is 
required for all patients enrolled in the study who consent to the biopsy, with or without the 
presence of grade 2 or above skin rash after initiation of erlotinib. A separate or immediate after 
clinic visit with the P.I. (TL) might be arranged to perform the skin biopsy as needed.  These 
samples (~400 mg) will be snapped frozen immediately in liquid nitrogen, and embedded in 
paraffin.   
 
Timing of tumor or skin biopsy: Pre-treatment biopsy could be obtained 2 weeks before 
initiation of the drug treatment. The onset of pemetrexed-related skin changes is less well 
defined but is usually accumulative for antimetabolites after 2-4 cycles. The onset of skin rashes 
is usually two weeks in patients and last for at least 24 hours after last dose of erlotinib in mice 
([80, 81] and data not shown), thus we will perform post-treatment skin biopsy during days 5-12 
(8 days) of cycle 2 or 3 of pemetrexed and/or erlotinib treatment.  See the following schemas. 
 
Schema of Skin Biopsies (Optional): 
D1
D8
D15
Arm A (Single Agent Arm)
D1
D8
D15
D1
D8
D15
= Alimta (pemetrexed) 500 mg/m2 IV D1
= Tarceva (erlotinib) 250 mg PO daily
= No drug given
PD, progressive disease.
Arm B (Concomitant Arm)
D1
D8
D15
PD*
D1
D8
D15
PD*
PD*
D1
D8
D15
Post-treatment skin biopsy: 
at cycle 2 (or 3) days 5-12 (8 days) of 
each treatment.
Pre-treatment skin biopsy: 
Within 7 days of treatment initiation.
After Arm A (Extension Study)
 


 
33
Schema of Tumor Biopsies (Optional): 
 
Week:
-2
-1
1
2
3
4
5           6          7…
Pre-treatment biopsy
Post-treatment biopsy
 
 
7.3.2 Tissue resources: 
The following tissue resources are allowed to collect tissue samples at the time of initial 
diagnosis, pre- and post-treatment.  
7.3.2.1 Formalin-fixed, paraffin-embedded (FFPE) tumor blocks 
7.3.2.2 Malignant pleural effusion 
7.3.2.3 Endobronchial brush and wash 
7.3.2.4 CT-guided core biopsy of tumor 
7.3.2.5 Punch biopsy of skin 
7.3.2.6 Peripheral blood 
 
7.3.3  The following assays will be performed: 
1. Histological Evaluation  
2. DNA isolation and mutational analysis 
3. FISH 
4. Tissue microarray (TMA) and Immunohistochemistry (IHC) 
5. ELISPOT assay 
 
Histological Evaluation: Specimens will be evaluated by routine hematoxylin and eosin (H&E) 
stain for the following assessments: 1) percentage of variable tumor; and 2) non-neoplastic 
adjacent normal tissue. 
 
DNA Isolation and Mutational Analyses: Tumor cells will be isolated on sections from FFPE 
tissue blocks by macrodissection if the slides consist of more than 75% of tumor. If the slides 
consist of less than 75% of tumor, we will first isolate tumor cells from normal cells on the slide 
onto a thin polymer film (CapSure LCM Caps, Arcturus, Mountain View, CA) by a PixCell IIe 
Laser Capture Microdissection (LCM) System (Arcturus, Mountain View, CA). The tumor cells 
will be dissociated from the film in proteinase K-containing lysis buffer.  The 75% is chosen 
arbitrarily. Our previous experience reveals that we can detect a heterozygous point mutation by 
direct sequencing if it is present at least at 15% (data not shown). An estimate of 3,000 to 10,000 
laser shots using a laser beam of 7.5-µm diameter will be needed to obtain enough analyzable 
DNA for at least 10 PCR reactions. As normal controls, DNA isolated from adjacent normal lung 
tissues either by LCM or by macrodissection (if normal tissues is >75%) will be used.  
 
 
Genomic DNA will be isolated from tumor samples by the DNeasy tissue kit (Qiagen). Targeted 
gene segments will be amplified by PCR and the mutation status will be determined by length 
analysis of fluorescently labeled PCR products (for EGFR exons 19, 20, and 21 deletions or 
mutations, K-Ras mutation, Cav-1 mutation) [82, 83] or by bi-directional sequencing. The 
sensitivity for the former test is about 5% and the sequencing is about 15%. The mutation rate of 
K-Ras, p53, EGFR, and caveolin-1 genes in the tumors will be compared and correlated with the 


 
34
smoking history of patients. Furthermore, these mutation statuses will be correlated with clinical 
efficacy to treatment. We have established all these methods in the laboratory.    
 
Fluorescence in situ hybridization (FISH): Recent studies suggest that a high copy number of 
EGFR gene is associated with increased response to erlotinib [84, 85] and/or survival in patients 
with advanced NSCLC [86]. We will determine the EGFR gene copy number using archival 
paraffin-embedded tissue blocks from routine diagnostic study. We will use the NSCLC cell 
lines that are known to have normal copy or amplified EGFR gene as negative and positive 
controls. The EGFR gene copy number is determined by FISH studies using dual-color DNA 
FISH probes specific for the EGFR locus (7p12) and the CEP7 chromosome 7 centromere 
(7p11.1 through q11.1). The result will be classified according to published six FISH categories 
[87]. EGFR amplification is defined as EGFR: CEP7 ≥ 2 or ≥ 15 per cell in ≥ 10% of cells [84]. 
In previous publication, 33-100 nonoverlapping nuclei of tumor cells were analyzed to determine 
the number of EGFR and CEP7 signals observed as well as the pattern of distribution of signals 
[84]. The studies will be performed at the Cytogenetic Laboratory in the Department of 
Pathology under the supervision of Dr. Ramesh.  
 
Tissue Microarray: The development of tissue arrays allows the evaluation of each of many 
proteins in many sets of normal and tumor tissues using a single slide for each probe. It provides 
a powerful way to follow up the candidate protein changes proposed in this study with control of 
technical variation. We will determine the changes in protein expression on tissue microarray 
(TMA) by IHC and correlate these altered protein changes with the clinical response to erlotinib 
and pemetrexed and with patient survival. Five-m sections of normal and tumor tissues 
embedded in paraffin will be stained with H&E to identify morphologically representative area 
of normal and tumor tissues, from which core biopsies will be taken. The tissue microarray will 
be done with the Tissue Arrayer (Beecher Instruments, Silver Spring, MD). From each specimen 
(donor), tissue cores with a diameter of 0.6 or 1.0 mm are punched and arrayed on a blank 
paraffin block (recipient). The spacing between the centers of two adjacent specimens on the 
array ranged from 3 mm to 8 mm. Two to three hundred cores could be created within the array 
block. Then the recipient block is incubated at 370C oven for 1 hour to soften the paraffin and 
melt the surface of the block.  
 
Immunohistochemistry (IHC): Tissue arrays containing diagnostic, pre- and post-treatment tumor 
and normal human NSCLC tissues (as described above) will be cut in 5-µm sections, 
deparaffinized, rehydrated, and quenched with 1.5% H2O2. For EGFR studies, the slides will be 
treated with DakoCytomation Target Retrieval Solution (DAKO, Carpinteria, CA) in a steam 
bath at 95°C for 45 minutes. After equilibration in PBS for 15 minutes, the slides were placed in 
an autostainer (DAKO, Carpinteria, CA) and stained with antibodies to EGFR (DAKO; 1:100 
dilution). Immunoreactivity will be detected using DAKO EnVision methods (DAKO) according 
to the manufacturer recommended procedures. The activated EGFR is detected using antibodies 
against the phosphorylated forms of EGFR (p-EGFR). Similar IHC staining will be performed 
using with antibodies specific for p53, K-Ras, caveolin-1 and other proteins as described 
previously.[88] For negative controls, slides will be treated with the same procedure, including 
antigen retrieval, except for omission of the primary antibodies. The level of expression will be 
assessed as percentage of positive staining cells, and scored as 0 (0%), +1 (1-25%), +2 (26-50%) 
and +3 (51-100%) as described before [89]. Cell pellets from human NSCLC cell lines known to 
be positive or negative for EGFR will be used as positive or negative controls for EGFR 
expression. Negative controls will also be performed by omission of the primary antibody. A 


 
35
sample of recording IHC results is illustrated in Appendix I. 
 
Human IFN-γ ELISA:  We will collect 5 ml of peripheral blood using citrate, EDTA, or heparin 
as anticoagulant from the patients before and 2 weeks after treatment. Plasma will be collected 
by centrifuging the blood for 10 minutes at 1000 x g within 20 minutes of collection. The plasma 
will be stored at ≤ 20°C or shipped on dry ice. We will analyze the patient plasma samples for in 
vitro T-cell function by ELISPOT assay using tumor specific antigens. A positive interferon 
gamma (IFN-γ) response to a common antigen (such as whole influenza virus or EBV) will be 
used as a control. The results will be correlated to the skin changes and clinical outcome of the 
patients.  
 
7.4 Statistical Analysis   
Due to the limited sample size of this Phase II study, analyses will be based on the combined 
data from both treatment groups. Exploratory data analyses will be performed to identify 
potential molecular and cellular markers of clinical efficacy in the two treatment arms. Data will 
first be summarized using standard descriptive statistics. The associations of EGFR/K-
Ras/p53/caveolin-1 gene mutation status (present/absent), EGFR gene amplification by FISH 
(present/absent) and other categorical markers with clinical outcome will be analyzed using the 
chi-square or Fisher’s exact when the outcome is clinical response.  Levels of continuous 
markers and changes in pre- and post-treatment levels will be compared between responder 
groups using the two-sample t-test or Wilcoxon rank sum test, depending on the distribution of 
the data.  When the outcome is progression-free survival, time to progression, or overall survival, 
standard time-to-event methods will be applied. Treatment specific analyses as well as 
multivariate analyses may also be performed provided the numbers of events are sufficient.  
 
 
7.5 Submission of Samples 
 
The research nurse and data manager (or clinical research coordinator) at each site will help 
the P.I. (TL) to organize and track sample submission and storage. 
 
7.5.1 Appendix D and E. 
 
7.5.2 A copy of each pathology report(s). 
 
7.5.3 Shipping procedures 
For any questions regarding sample handling and shipping, please contact the overall PI Dr. 
Tianhong Li at 916-734-3772 to confirm with the recipient before shipping.   
All samples should be packed upright in sufficient dry ice (2-5 lbs) to ensure that they remain 
frozen during transfer. 
A federal Express account has been created for overnight shipping. 
Shipping address:  
Dr. Tianhong Li,  
UC Davis Cancer Center 
Division of Hematology & Oncology 
4501 X Street, Suite 3016 
Sacramento, CA  95817 
Email: tianhong.li@ucdmc.ucdavis.edu 
Phone: 916.734.3772 


 
36
8. STUDY CALENDAR 
Baseline laboratory tests are to be conducted within 2 weeks prior to registration.  All 
patients will be screened for brain metastasis prior to registration. Scans (CT, MRI, or 
PET/CT) and x-rays must be donewithin 4 weeks prior to registration.  In the event that the 
patient's condition might have changed, laboratory evaluations should be repeated within 48 
hours prior to initiation of the next cycle of therapy. 
   
 
Pre-
Study* 
(within 
2-4wks 
prior) 
 
C1 
D1 
 
C1 
D8 
 
C1 
D15 
 
C2 
D1 
 
C2 
D8 
 
C2 
D15 
 
C3 
D1 
 
C3 
D8 
 
C3 
D15 
 
C4 
D1 
 
C4 
D8 
 
C4 
D15 and 
beyond 
 
Off 
Studyc 
 
Arm A or B: Pemetrexed 
 
 
 
A 
 
 
 
 
 
A 
 
 
 
 
 
A 
 
 
 
 
 
A 
 
 
 
 
 
 
 
Arm B: concomitant with 
Erlotinib 
 
 
 
B: D2----------D17   B: D2----------D17   B: D2-----------D17   B: D2------------D17  
 
 
 
Extension Study: Erlotinib 
 
After 
Arm A 
 
B: D1  D21 
continuously 
 
B: D1  D21 
continuously 
 
B: D1  D21 
continuously 
 
B: D1  D21 
continuously 
 
 
 
Informed consent 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical/Smoking history 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Concurrent meds 
 
X 
 
X-------------------------------------------------------------------------------------------------X 
 
 
 
Physical exam 
 
X 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
Vital signs 
 
X 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
Height 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight 
 
X 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
Performance status 
 
X 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
CBC w/diff, platelets 
 
X 
 
X 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
Serum chemistrya 
 
X 
 
X 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
EKG (as indicated) 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse event evaluation 
 
 
 
X-------------------------------------------------------------------------------------------------X 
 
X 
 
Tumor measurements 
X 
Tumor measurements are repeated every 6 weeks (i.e., 2 cycles)  during the first year. 
Starting in the second year, the frequency is every 3 cycles. Documentation (radiologic) 
must be provided for patients removed from study for progressive disease. 
Xc 
 
Folic acid and Vit B12,  
homocysteine 
 
X 
Folic Acid (400 µg, i.e., 0.4 mg) and Vitamin B12 (1000 µg) must be given daily 
beginning approximately one week prior to first dose of Alimta.  (See section 4.3). 
Subsequent blood draws for folic acid and Vit B12 are only needed if clinically indicated.  
 
 
 
Head CT or MRI scan 
 
X 
All patients will be screened for brain metastasis within 6 weeks prior to registration. 
Subsequent images should be performed according to patient’s symptom only. 
Xc 
 
Radiologic evaluation 
Xd 
 
Radiologic measurements should be performed every 6 weeks (i.e., 2 cycles).  
Xc 
 
beta-HCG 
 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other tests, as appropriate 
 
 
 Optional 
 
 
 
Other correlative studies 
 
 
 Optional 
 
 
Abbreviations:  
A, Pemetrexed (Dose as assigned); B, Erlotinib (Dose as assigned); C, cycle; D, day. 
a: 
Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, phosphorus, potassium, total protein, 
SGOT [AST], SGPT [ALT], sodium.  
b: 
Serum pregnancy test (women of childbearing potential) within 14 days prior to start of treatment 
c: 
Off-study evaluation.  
d:  
Any  response (CR, PR) or SD need to be confirmed by a repeat radiographic measurement after initial documentation (See Section 
9.4.1). 


 
37
9. MEASUREMENT OF EFFECT 
 
For the purposes of this study, patients should be re-evaluated for response every 3 weeks.  
In addition to a baseline scan, confirmatory scans should also be obtained 4 weeks following 
initial documentation of objective response. 
 
9.1. 
Definitions 
 
Response and progression will be evaluated in this study using the new international 
criteria proposed by the Response Evaluation Criteria in Solid Tumors (RECIST) 
Committee [90]. Changes in only the largest diameter (unidimensional measurement) 
of the tumor lesions are used in the RECIST criteria. Note:  Lesions are either 
measurable or non-measurable using the criteria provided below.  The term 
“evaluable” in reference to measurability will not be used because it does not provide 
additional meaning or accuracy. 
 
9.1.1 
Measurable disease 
Measurable lesions are defined as those that can be accurately measured in at 
least one dimension (longest diameter to be recorded) as >20 mm with 
conventional techniques (CT, MRI, x-ray) or as >10 mm with spiral CT scan.  
All tumor measurements must be recorded in millimeters (or decimal fractions 
of centimeters). 
 
9.1.2 
Non-measurable disease 
All other lesions (or sites of disease), including small lesions (longest 
diameter <20 mm with conventional techniques or <10 mm using spiral CT 
scan), are considered non-measurable disease. Bone lesions, leptomeningeal 
disease, ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonis, 
inflammatory breast disease, abdominal masses (not followed by CT or MRI), 
and cystic lesions are all non-measurable. 
 
9.1.3 
Target lesions 
All measurable lesions up to a maximum of five lesions per organ and 10 
lesions in total, representative of all involved organs, should be identified as 
target lesions and recorded and measured at baseline.  Target lesions should 
be selected on the basis of their size (lesions with the longest diameter) and 
their suitability for accurate repeated measurements (either by imaging 
techniques or clinically).  A sum of the longest diameter (LD) for all target 
lesions will be calculated and reported as the baseline sum LD.  The baseline 
sum LD will be used as reference by which to characterize the objective tumor 
response. 
 
9.1.4 Non-target lesions 
All other lesions (or sites of disease) should be identified as non-target 
lesions and should also be recorded at baseline.  Non-target lesions include 
measurable lesions that exceed the maximum numbers per organ or total of all 
involved organs as well as non-measurable lesions.  Measurements of these 


 
38
lesions are not required but the presence or absence of each should be noted 
throughout follow-up.  
9.2  
Guidelines for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or 
calipers.  All baseline evaluations should be performed as closely as possible to the 
beginning of treatment and never more than 6 weeks before the beginning of the 
treatment. 
 
Note: Tumor lesions that are situated in a previously irradiated area might or might 
not be considered measurable.   
 
The same method of assessment and the same technique should be used to 
characterize each identified and reported lesion at baseline and during follow-up. 
Imaging-based evaluation is preferred to evaluation by clinical examination when 
both methods have been used to assess the antitumor effect of a treatment. 
 
Clinical lesions.  Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes).  In the case of skin lesions, 
documentation by color photography, including a ruler to estimate the size of the 
lesion, is recommended.  
 
Chest x-ray.  Lesions on chest x-ray are acceptable as measurable lesions when they 
are clearly defined and surrounded by aerated lung.  However, CT is preferable.  
 
Conventional CT and MRI.  These techniques should be performed with cuts of 10 
mm or less in slice thickness contiguously.  Spiral CT should be performed using a 5 
mm contiguous reconstruction algorithm.  This applies to tumors of the chest, 
abdomen, and pelvis.   
 
Tumor markers.  Tumor markers alone cannot be used to assess response.   
 
Cytology and Histology.  These techniques can be used to differentiate between 
partial responses (PR) and complete responses (CR) in rare cases (e.g., residual 
lesions in tumor types, such as germ cell tumors, where known residual benign 
tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or 
worsens during treatment when the measurable tumor has met criteria for response or 
stable disease is mandatory to differentiate between response or stable disease (an 
effusion may be a side effect of the treatment) and progressive disease. 
 
9.3  
Response Criteria 
 
9.3.1 Evaluation of target lesions 
 
Complete Response (CR):Disappearance of all target lesions  
 
Partial Response (PR): 
 
At least a 30% decrease in the sum of the 


 
39
longest diameter (LD) of target lesions, taking 
as reference the baseline sum LD 
 
Progressive Disease (PD): 
At least a 20% increase in the sum of the LD of 
target lesions, taking as reference the smallest 
sum LD recorded since the treatment started or 
the appearance of one or more new lesions 
 
Stable Disease (SD):  
Neither sufficient shrinkage to qualify for PR 
nor sufficient increase to qualify for PD, taking 
as reference the smallest sum LD since the 
treatment started 
 
 
9.3.2 Evaluation of non-target lesions 
 
Complete Response (CR): 
Disappearance of all non-target lesions and 
normalization of tumor marker level 
 
Incomplete Response/  
Stable Disease (SD):  
Persistence of one or more non-target lesion(s) 
and/or maintenance of tumor marker level above 
the normal limits  
 
Progressive Disease (PD): 
Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target 
lesions 
 
Although a clear progression of “non-target” lesions only is exceptional, in 
such circumstances the opinion of the treating physician should prevail, and 
the progression status should be confirmed at a later time by the review panel 
(or study chair). 
Note:  If tumor markers are initially above the upper normal limit, they must 
normalize for a patient to be considered in complete clinical response. 
 
9.3.3 Evaluation of best overall response 
 
The best overall response is the best response recorded from the start of the 
treatment until disease progression/recurrence (taking as reference for 
progressive disease the smallest measurements recorded since the treatment 
started).  The patient's best response assignment will depend on the 
achievement of both measurement and confirmation criteria (see section 
9.3.1). 
 
 
 
 
 
 


 
40
 
Target Lesions 
 
Non-Target Lesions 
 
New Lesions 
 
Overall Response 
 
CR 
 
CR 
 
No 
 
CR 
 
CR 
 
Incomplete 
response/SD 
 
No 
 
PR 
 
PR 
 
Non-PD 
 
No 
 
PR 
 
SD 
 
Non-PD 
 
No 
 
SD 
 
PD 
 
Any 
 
Yes or No 
 
PD 
 
Any 
 
PD 
 
Yes or No 
 
PD 
 
Any 
 
Any 
 
Yes 
 
PD 
 
Note: 
 Patients with a global deterioration of health status requiring 
discontinuation of treatment without objective evidence of disease 
progression at that time should be classified as having “symptomatic 
deterioration.”  Every effort should be made to document the objective 
progression, even after discontinuation of treatment. 
 
 In some circumstances, it may be difficult to distinguish residual disease 
from normal tissue.  When the evaluation of complete response depends 
on this determination, it is recommended that the residual lesion be 
investigated (fine needle aspirate/biopsy) before confirming the complete 
response status. 
 
9.4  
Confirmatory Measurement/Duration of Response 
 
9.4.1 Confirmation 
 
To be assigned a status of PR or CR, changes in tumor measurements must be 
confirmed by repeat assessments that should be performed 4 weeks after the 
criteria for response are first met.  In the case of SD, follow-up measurements 
must have met the SD criteria at least once after study entry at a minimum 
interval of 4 weeks (see section 9.3.3). 
 
9.4.2 Duration of overall response 
 
The duration of overall response is measured from the time measurement 
criteria are met for CR or PR (whichever is first recorded) until the first date 
that recurrent or progressive disease is objectively documented (taking as 
reference for progressive disease the smallest measurements recorded since 
the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria 
are first met for CR until the first date that recurrent disease is objectively 
documented. 


 
41
 
9.4.3 Duration of Stable Disease 
 
Stable disease is measured from the start of the treatment until the criteria for 
progression are met, taking as reference the smallest measurements recorded 
since the treatment started.  
 
9.5  
Progression-Free and Overall Survival 
 
Progression-Free Survival (PFS) is the time from randomization until objective tumor 
progression or death from any cause.  PFS is censored at the date of the last follow-up 
visit for patients who are still alive and who have not progressed.  Overall survival 
(OS) time is defined as the time from the date of randomization to date of death due 
to any cause.  
 
9.6  
Response Review 
 
All responses will be reviewed by an expert(s) independent of the study at the study’s 
completion. 
 
 
10. REGULATORY AND REPORTING REQUIREMENTS 
 
Adverse events (AEs) will use the descriptions and grading scales found in the revised 
Common Terminology Criteria for Adverse Events (CTCAE) version 3.0 (Appendix C). A 
list of adverse events that have occurred or might occur (Reported Adverse Events and 
Potential Risks) can be found in Section 6 (Pharmaceutical Information).  The reported 
procedures to be followed are presented in the investigators’ brochures.    
 
10.1 
Expedited Adverse Event Reporting 
(AE; formerly known as Adverse Drug Reaction) 
 
Study site personnel must notify the Sponsor (Montefiore Medical Center), Eli Lilly 
and Company, OSI Pharmaceuticals, and all participating investigators and sites 
immediately of any “serious” (defined below) adverse event experienced by a patient.  
In addition, adverse events must be reported to regulatory authorities according to the 
definitions and timelines specified in the local laws and regulations. 
Serious events are defined as those that result in: 
 
Death. 
 
Initial or prolonged inpatient hospitalization. 
 
A life-threatening situation (where the patient is at immediate risk of 
death). 
 
Severe or permanent disability. 
 
Congenital anomaly. 
 
Or, is significant for any other reason. 
 
Serious adverse events occurring after a patient is discontinued from the study will 
NOT be reported unless the investigator feels that the event may have been caused by 
the study drug or a protocol procedure.  Study-specific clinical outcomes of death 


 
42
because of disease progression are exempt from serious adverse event reporting, 
unless the investigator deems them related to use of the study drug.  Hospitalization 
for study drug administration is not a serious adverse event. 
 
In general, serious adverse events assessed as clearly being due to disease 
progression, and not due to study drug(s), should be excluded from adverse event 
reporting. However, in cases where the specificity or severity of an event is not 
consistent with the risk information, the event should be reported. 
 
10.2 
Reporting Serious Adverse Events Associated with Pemetrexed (Alimta) 
 
Pharmacovigilance Fax Number for Alimta Related SAEs:  317-277-0853 
 
10.3 
Reporting Serious Adverse Events Associated with Erlotinib (Tarceva) 
All serious adverse events that are considered related to Tarceva treatment must be 
recorded on a MedWatch 3500 Form and faxed within 1 business day to:   
 
OSI Drug Safety: Fax number: 303-546-7706 
For questions related to erlotinib safety reporting, please call the phone number 303-
546-7869 
 
MedWatch 3500 Reporting Guidelines: 
Note:  MedWatch 3500 forms and other information related to MedWatch reporting 
are available at http://www.fda.gov/medwatch/index.html. 
 
In addition to completing appropriate patient demographic, suspect medication and 
reporter information, the report should include the following information within the 
Event Description of the MedWatch 3500 form: 
– Protocol description (and number, if assigned) 
– Description of event, severity, treatment, and outcome if known 
– Supportive laboratory results and diagnostics 
– Investigator’s assessment of the relationship of the adverse event to each 
investigational product and suspect medication 
 
10.4 
Reporting of Regulatory Documents (Protocol Deviations, Violations, or 
Amendments):   
 
 
 
All sites should first submit their regulatory documents, including protocol 
deviations, violations, amendments, or others, to the Sponsor (PI: Dr.Roman Perez-
Soler, Montefiore Medical Center). The Sponsor will submit any significant changes 
to Eli Lilly and Company, OSI Pharmaceuticals, and all participating investigators 
and sites. 
 
11. STATISTICAL CONSIDERATIONS 
 
11.1 
Study Design/Analytic Plan 
 
The primary statistical objectives of this randomized Phase II study are to obtain 


 
43
preliminary estimates of the magnitude and variability of the efficacy of combination 
treatment with Alimta® and Tarceva®.  Data from the control arm, single agent 
Alimta®, will be used to evaluate whether the observed efficacy in this study 
population is similar to the expected efficacy based on prior studies and aid in the 
interpretation of the results on the concurrent arm [91]. The two treatment arms will 
not be formally compared.  
 
The primary endpoint of the study is progression- free survival (PFS).   PFS is 
defined as the time from randomization until documented tumor progression or death 
from any cause. PFS is censored at the date of the last follow-up visit for patients who 
are still alive and who have not progressed. The rationale for choosing PFS as the 
primary endpoint is that the response rate is generally low and any survival benefit is 
hard to document in second-line treatment of advanced NSCLC. In addition, the 2005 
consensus of the FDA’s Oncologic Drug Advisory Committee (ODAC) was that PFS 
is a better predictor of clinical benefit than time to progression (TTP) because PFS 
includes death as an outcome whereas TTP is based only on objective tumor 
progression [92]. 
 
Secondary objectives are to evaluate objective overall response rate [ORR, i.e., 
complete response (CR) + partial response (PR)],  disease control rate (CR+PR+SD), 
overall survival (OS), time to progression (TTP), duration of response, and toxicities 
in these patients. OS is defined as the time from the date of randomization to date of 
death due to any cause. Time to progression (TTP) is defined as the time from the 
date of randomization to the first date of documented disease progression.  
 
Response rates in each arm will be summarized by computing proportions and 
corresponding 95% confidence intervals. Time to event endpoints will be analyzed 
using standard survival analytic methods, including the Kaplan-Meier approach for 
estimating the survival distributions. Median time to event and 95% confidence 
intervals will be estimated from the Kaplan-Meier curves. All primary and secondary 
analyses will be based on the intent-to-treat principle. 
 
11.2 
Sample Size/Accrual Rate 
 
We choose the patients with advanced NSCLC for a second-line therapy as study 
subjects. This is consistent with the current FDA label of the two drugs as single 
agents and supported by our preclinical data that chemo-resistant NSCLC cells are 
more dependent on EGFR signaling pathway for growth and survival.  
 
Patients will be randomized 2:1 to the combination versus single agent treatment 
groups to encourage accrual rate. The target sample size is 50 patients assigned to the 
combination therapy and 25 subjects to pemetrexed alone, for a total of 75 patients. 
To account for a ~10% dropout rate, 82 patients will be enrolled.  For the 
combination arm, the treatment would be considered worthy of further study if it 
increased the median PFS from approximately 3 months to 4.5 months.  For the 
purpose of evaluating the power of the study, we focus on the PFS rate at 6 months. 
Assuming an exponential distribution, a median PFS of 3 months corresponds to a 
PFS rate of 24% at 6 months of follow-up; a median PFS of 4.5 months corresponds 
to a PFS rate of 41% at 6 months of follow-up.  The targeted sample size is 50 in the 
combination arm. This is required for the combination arm to have 80% power to 


 
44
detect an increase in the 6 month PFS survival rate from 24% to 41%, assuming a 
Type I error rate of 5%.   
 
An interim analysis will be performed after the first 20 patients on the combination 
arm had been followed for a minimum of 3 months. If the upper limit of the 95% 
confidence interval for the 3-month PFS rate is less than 50%, or equivalently, that 
we can conclude that the median PFS is less than 3 months, the study will be 
terminated early. This will occur if 15 or more of the first 20 patients have failed by 3 
months.   
 
In the single agent arm, the target sample size is 25 patients. As indicated earlier, the 
purpose of enrolling patients on this standard therapy arm is not to formally compare 
it with the combination arm, but rather to assess whether the observed efficacy in this 
study population is similar to the expected efficacy based on prior studies and also to 
aid in the interpretation of the results on the combination arm. If the observed 6 
month PFS is equal to the expected value of 24%, then with a sample size of 25 
patients, the corresponding 95% CI will be 7.3% - 41%.  
 
The power of the study will be insufficient to allow for a direct comparison between 
treatment arms; again, however, this is not the primary objective of the study. It is 
designed to obtain preliminary estimate of the clinical efficacy of pemetrexed 
followed by erlotinib in advanced NSCLC patients. If the data from this randomized 
Phase II trial indicate that the combination arm may be efficacious, the results will be 
utilized to design a larger scale Phase III trial to formally compare the single agent 
and combination therapies.  
 
The accrual period is assumed to be approximately 36 months (3-4 patients/month), 
with a follow-up period of an additional 12 months after the last patient is enrolled.  
 
11.3 
Randomization and Stratification  
 
Patients enrolled into the trial will be randomized 2:1 to the concomitant pemetrexed 
and erlotinib or single agent pemetrexed using a computer generated randomization 
list provided by the study statistician. Patients will be stratified by gender, histology 
(adenocarcinoma versus others), performance status (0/1 versus 2), and prior smoking 
[≤15 versus >15 pack years (PY)].  
 
11.4 
Analyses for Correlative Studies 
 
See section 7.4. 
 
11.5 
Reporting and Exclusions 
 
 
 
11.5.1 Evaluation of toxicity.   
 
All patients will be evaluated for toxicity from the time of their first treatment with 
pemetrexed and erlotinib.  
 
11.5.2 Evaluation of response.   
All patients who meet the eligibility criteria and have received at lease one dose of 
treatment will be assessed for response to treatment, even if there are major protocol 


 
45
treatment deviations.  Each patient will be assigned one of the following categories:  
1) complete response, 2) partial response, 3) stable disease, 4) progressive disease, 5) 
early death from malignant disease, 6) early death from toxicity, 7) early death 
because of other cause, or 9) unknown (not assessable, insufficient data).  [Note:  By 
arbitrary convention, category 9 usually designates the “unknown” status of any type 
of data in a clinical database.] 
 
Patients in response categories 4-9 should be considered as failing to respond to 
treatment (disease progression). Thus, an incorrect treatment schedule or drug 
administration does not result in exclusion from the analysis of the response rate.  
Precise definitions for categories 4-9 will be protocol specific.  
 
 
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