A phase I study of continuous infusion 5-fluorouracil plus calcium leucovorin in combination with N-(phosphonacetyl)-L-aspartate in metastatic gastrointestinal adenocarcinoma.

Preclinical studies suggest that the biochemical effects of N-(phosphonacetyl)-L-aspartate (PALA), an inhibitor of aspartate carbamoyltransferase (ACTase), may increase the metabolic activation of 5-fluorouracil (5-FU) and enhance its cytotoxicity through both RNA- and DNA-directed mechanisms. In this Phase I trial, 22 evaluable patients with adenocarcinoma of the gastrointestinal tract were entered at escalating doses of 5-FU starting at 1150 mg/m2/day given as a concurrent 72-h i.v. infusion with a fixed dose of leucovorin (LCV), 500 mg/m2/day. The dose of 5-FU was escalated within patients according to individual tolerance, and then PALA at 250 mg/m2 was added 24 h prior to the initiation of the 5-FU/LCV infusion of the subsequent cycle. Dose-limiting mucositis and myelosuppression occurred during the initial cycle in 3 of 5 patients treated with 2300 mg/m2/day 5-FU; therefore, the recommended dose of 5-FU with concurrent LCV is 2000 mg/m2/day. Twenty-seven additional patients were then treated with escalating doses of PALA ranging from 375 to 2848 mg/m2, i.v., followed 24 h later by 2000 mg/m2/day 5-FU with high-dose LCV. Dose-limiting mucositis and myelosuppression occurred during the initial cycle in 2 of 3 patients entered at 2848 mg/m2 PALA. Dose-limiting mucositis and skin rash ultimately required both PALA and 5-FU dose reductions in 4 of 6 patients treated with 1899 mg/m2 PALA. Toxicity was similar, however, in patients receiving PALA at doses ranging from 375 to 1266 mg/m2. The mean steady-state plasma concentration of 5-FU at 2000 mg/m2/day was 6.5 +/- 0.9 microM; patients with 5-FU levels > 9 microM had a significantly higher incidence of serious gastrointestinal and hematological toxicity. Compared to each patient's own baseline, a significant trend for decreasing ACTase activity with increasing PALA dose was evident using cytosol isolated from peripheral blood mononuclear cells 24 h after PALA treatment (P2 = 0.01). PALA < or = 844 mg/m2 failed to appreciably inhibit ACTase activity at 24 h in most patients; furthermore, a decrease in ACTase activity by > 50% from baseline was seen in only 29% of cycles. More consistent inhibition of ACTase activity was seen with PALA > or = 1266 mg/m2. Even with the highest PALA doses, however, ACTase activity returned to baseline by 96 h in most patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Elevation of pyrimidine enzyme activities in the RBC of patients with congenital hypoplastic anaemia and their parents.

The activities of orotate phosphoribosyl transferase (OPRT) and orotidine monophosphate decarboxylase (ODC) were significantly elevated (P less than 0.001) in erythrocytes (RBC) from five patients with prednisone-responsive congenital hypoplastic anaemia (CHA). (OPRT: patients - 10.1--64.2 nmol/h/10(9) RBC; controls - 2.8 +/- 0.3 (mean +/- SEM, n = 37); ODC: patients = 30--124 nmol/h/10(9) RBC; controls = 10.2 +/- 0.7 (mean SEM, n = 37).) Two patients had a less pronounced, but significant, increase of aspartate transcarbamylase activity and three patients had marginal increases of dihydroorotase activity. Dihydroorotate dehydrogenase activity was not detected in any CHA patient or control. In one patient prior to prednisone therapy, the OPRT and ODT activities were elevated 10-fold and remained elevated 3-fold after 16 months of therapy. An elevated enzyme pattern similar to that of RBC from CHA patients was observed in three parents of three CHA patients, but not in three parents of two other CHA patients. The activities of all five pyrimidine enzymes were normal for one patient with transient erythroblastopenia of childhood. In contrast, the activities of all the pyrimidine biosynthetic enzymes were elevated in blood from patients with a young RBC population: sickle cell anaemia, sickle-beta-thalassaemia, hereditary spherocytosis, and DiGuglielmo syndrome and from the newborn. It is postulated that factors which affect the activities of pyrimidine enzymes in CHA may also result in diminished erythropoiesis.

Measurement of aspartate carbamoyltransferase activity by high performance liquid chromatography.

We developed an assay which permits measurement of aspartate carbamoyltransferase (ACTase) activity. Cytosol from human peripheral blood mononuclear cells was used as the enzyme source. Using [14C]carbamoyl phosphate as the radiolabeled substrate, the formation of [14C]carbamoyl aspartate was quantitated by high performance liquid chromatography (HPLC) using an anion-exchange column with UV detection at 200-280 nm and an on-line liquid scintillation detector. A gradient method from an initially low concentration of ammonium phosphate, 1 mM (pH 3.0), to a higher concentration, 38 mM (pH 4.5), was used. The apparent Km values of carbamoyl phosphate and aspartate were 58 microM and 1.9 mM, respectively. ACTase inhibition by N-(phosphonacetyl)-l-aspartate (PALA) was consistent with a competitive model with respect to carbamoyl phosphate. The assay conditions were optimized to permit measurement of ACTase activity prior to and following therapy with PALA; ACTase was inhibited in a dose-dependent manner. This HPLC method permits direct quantitation of both the product of the reaction and the initial integrity of the substrate, [14C]carbamoyl phosphate, which is unstable in aqueous solutions.

Peripheral leukocytes as indicators of the enzymatic effects of N-(phosphonacetyl)-L-aspartic acid (PALA) on human L-aspartate transcarbamoylase (ATCase) activity.

The interaction of N-(phosphonacetyl)-L-aspartic acid (PALA) with L-aspartate transcarbamoylase (ATCase), the putative target for the antineoplastic activity of this drug, has been studied in the blood of patients participating in a phase I trial of PALA. ATCase activity in human blood is most abundant in granulocytes and lymphocytes; comparatively little activity is seen in erythrocytes. Utilizing peripheral leukocytes from patients given infusions of PALA, we find that leukocyte ATCase in inhibited rapidly and strongly. After cessation of therapy the rate of restitution of enzyme activity is slow: half-maximal restoration is achieved in about 280 hours. As a correlate of this gradual recovery of enzymatic activity, nanomolar concentrations of PALA are detectable in the plasma 2 weeks after infusion. The apparent Ki of PALA for leukocyte ATCase with carbamoyl phosphate as the variable substrate is 5 nM. Uptake of PALA into leukocytes in vitro is saturable and occurs at a moderate rate comparable to that measured in murine tumor cells. Correspondingly, inhibitory concentrations of PALA (approximately 10(-7) M) are found in the leukocytes of patients throughout the course of PALA treatment. It is concluded that although leukocytes are not targets for PALA toxicity, they may serve as accessible and pertinent indicators of the enzymatic effects of this new oncolytic drug.

Phase I study of continuous-infusion PALA and 5-FU.

Eighteen patients with malignancies refractory to conventional forms of therapy were treated with 5-day continuous infusions of PALA and 5-FU. PALA was administered at a dose of 940 mg/m2/day. 5-FU was initially given at a dose of 180 mg/m2/day and was incrementally increased to 325 mg/m2/day. The courses were repeated every 3-4 weeks. Mucositis and diarrhea were the dose-limiting toxic effects. Other reversible side effects included grade 2 skin rashes and nausea and vomiting. Peak plasma PALA concentrations were approximately 20 microM and occurred in conjunction with a maximum depression of leukocyte-L-aspartate transcarbamylase (ATCase) activity to 10% of baseline. Therapeutic responses occurred in one of the 13 patients with colon carcinoma and in one patient with mammary carcinoma. Responses could not be correlated with leukocyte ATCase depression. Recent data indicate that low doses of PALA (250 mg/m2) might be equally as effective in inhibiting leukocyte ATCase activity as the doses used in this study. A phase II trial has been designed at this institution employing the above doses of PALA in conjunction with escalating doses of 5-FU.