Cancer Chemother Pharmacol (2013) 72:7583
DOI 10.1007/s00280-013-2170-5
ORIGINAL ARTICLE
Phase I study of weekly kahalalide F as prolonged infusion
in patients with advanced solid tumors
R. Salazar H. Cortes-Funes E. Casado B. Pardo A. Lopez-Martn
C. Cuadra J. Tabernero C. Coronado M. Garca A. Soto Matos-Pita
B. Miguel-Lillo M. Cullell-Young J. L. Iglesias Dios L. Paz-Ares
Received: 14 January 2013 / Accepted: 17 April 2013 / Published online: 5 May 2013
Springer-Verlag Berlin Heidelberg 2013
Abstract
Purpose Kahalalide F (KF) is a dehydroaminobutyric
acid-containing peptide from marine origin with activity
against several human malignant cell lines. This dose-
escalating phase I clinical trial evaluated the maximum
tolerated dose (MTD), and the recommended dose for
further phase II studies (RD) of weekly KF given as a
prolonged (3- to 24-h) intravenous (i.v.) infusion.
Methods Eligible patients with advanced solid tumors
and adequate performance status, hematologic, renal, and
hepatic function were recruited into this study.
Results A total of 106 patients were treated with KF at
four different weekly schedules: 3-h (n = 40), 24-h
(n = 59), and two transitional schedules [6-h (n = 4) and
12-h (n = 3)]. For the 3-h weekly schedule, the MTD was
1,200 lg/m2 and the RD was 1,000 lg/m2. For the 24-h
weekly schedule, the MTD was reached (6,650 lg/m2), but
the RD could not be confirmed. Asymptomatic and
reversible grade 3/4 transaminase increase was the most
common dose-limiting toxicity in both schedules. Fatigue,
R. Salazar (&)
B. Pardo
C. Cuadra
M. Garca
Instituto Catalan de Oncologa, Ctra. Gran Va, 08907 s/n.
LHospitalet de Llobregat, Barcelona, Spain
e-mail: ramonsalazar@iconcologia.net
H. Cortes-Funes
A. Lopez-Martn
C. Coronado
L. Paz-Ares
Hospital Universitario Doce de Octubre, Madrid, Spain
E. Casado
J. Tabernero
Hospital Vall dHebron, University Hospital, Universitat
Autonoma de Barcelona, Barcelona, Spain
A. Soto Matos-Pita
B. Miguel-Lillo
M. Cullell-Young

J. L. Iglesias Dios
Pharma Mar, S.A. Sociedad Unipersonal, Colmenar Viejo,
Madrid, Spain
paresthesia, pruritus, nausea, vomiting, and rash were the
most common KF-related adverse events. No major devi-
ations from linearity were detected in the pharmacokinetic
(PK) profiles of both schedules, which showed a narrow
distribution and short body residence. Prolonged disease
stabilization (C3 months) occurred in eight patients: two
with the 3-h schedule and six with the 24-h schedule.
Conclusions Administration of KF as prolonged weekly
infusion appears feasible, with 3-h and 24-h infusion times
having an acceptable safety profile.
Keywords Kahalalide
Advanced solid tumors
Marine
compounds
Phase I clinical trials
Introduction
Kahalalide F (KF) is a dehydroaminobutyric acid-con-
taining peptide isolated from the herbivorous marine mol-
lusk Elysia rufescens [13]. KF was active against several
human malignant cell lines both in vitro and in vivo [4, 5].
Several mechanisms of action have been proposed for the
antitumor activity of KF, such as alterations in the lyso-
somal membrane, inhibition of the erbB2 tyrosine kinase
activity, inhibition of transforming growth factor-a (TGF-
a) gene expression, cell cycle block in the G0G1 stage,
and blockage of epidermal growth factor (EGF) receptors
[69]. In addition, KF induces non-p53-mediated apoptosis
without causing damage to DNA, and a selective cytotoxic
effect on neu? cells overexpressing Her2 without inhibit-
ing autophosphorylation or MEK kinase activity [5].
Previous phase I trials established transient and
asymptomatic transaminases increases starting soon after
the first administration as the main dose-limiting toxicity
(DLT) associated with single-agent KF when given to adult
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cancer patients as a 1-h intravenous (i.v.) infusion weekly
(qw) or for five consecutive days in 21-day cycles
(dx5q3w) [10, 11]. A relatively low median volume of
distribution (5.5 l) and a short median half-life (0.52 h)
were found with the 1-h infusion [11]. The fact that the
recommended dose per infusion was very similar in both
schedules (560 lg/m2 in the dx5q3w schedule and 650 lg/
m2 in the qw schedule) suggests that transaminases
increases found at the maximum tolerated dose (MTD) in
previous phase I trials might be dependent on the maxi-
mum KF concentration in plasma (Cmax). Hence, longer
infusion times could help to reduce the incidence of this
DLT and to achieve a longer KF exposure. The current
dose-escalating phase I clinical trial had the aim of iden-
tifying a suitable schedule and recommended dose for
phase II trials (RD) of weekly KF administered i.v. at
infusion times longer than 1 h in patients with advanced
solid tumors. The safety, pharmacokinetics (PK), and
antitumor activity of these KF schedules were also
evaluated.
Materials and methods
This clinical trial was conducted at three centers in Spain
according to the good clinical practice requirements and
the declaration of Helsinki. The protocol was approved by
the Clinical Research Ethics Committee of each center. A
signed written informed consent was obtained for each
patient before any study procedure was done.
Eligibility criteria
The study enrolled adult patients diagnosed with advanced
malignant solid tumors for which no effective conventional
therapy existed; recovered from any toxicity derived from
the previous treatments; Eastern Cooperative Oncology
Group performance status (ECOG PS) B2; life expectancy
[3 months, and adequate organ function [neutrophil
count [ 1.0 9 109/l, platelet count [100 9 109/l, hemo-
globin [9 g/dl; aspartate aminotransferase (AST) and ala-
nine aminotransferase (ALT)\2.5 9 upper limit of normal
(ULN); bilirubin \1.5 9 ULN; creatinine clearance
[40 ml/min].
Patients were excluded if they had received prior ther-
apy with KF, any investigational product within 30 days
prior to inclusion or any antitumor therapy within 4 weeks
prior to inclusion (6 weeks in case of mitomycin C, ni-
trosoureas, or temozolamide); if they had evidence of
cerebral involvement; were pregnant or lactating women,
or men and women not using effective contraceptive
methods; had active bacterial infection, known human
immunodeficiency virus (HIV) infection, known chronic
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Cancer Chemother Pharmacol (2013) 72:7583
liver disease, grade C2 peripheral or sensory neuropathy,
or another nonmalignant disease considered incompatible
with the protocol; or a history of myocardial infarction,
uncontrolled angor pectoris or arrhythmia requiring medi-
cation, or hypersensitivity to any drug formulated in
Cremophor.
Study treatment and dose escalation
Kahalalide F was supplied by PharmaMar as a sterile
lyophilized product. Vials with two different KF strengths
(50 or 150 lg) were reconstituted by adding 1.5 ml (50-lg
vials) or 3 ml (150-lg vials) of reconstitution solution
[Cremophor/Ethanol/Water at 15/15/70 % (v/v/v)]. The
resulting solution was further diluted in normal saline
solution (0.9 % NaCl for injection) before i.v. adminis-
tration. In addition, patients treated with KF at infusion
times shorter than 24 h were premedicated with H1-
receptor and H2-receptor antagonists at 30 min before each
KF infusion. Further premedication with dexamethasone
20 mg i.v. or equivalent was to be given if hypersensitivity
reactions were experienced. Secondary prophylactic an-
tiemetics, red blood cell transfusions and/or erythropoietin
were allowed.
The starting dose was 530 lg/m2 given as a 3-h weekly
infusion; this was lower than the RD of 650 lg/m2 estab-
lished previously for KF given as a weekly 1-h infusion [11].
Each KF infusion was considered one cycle. Dose escalation
is summarized in Table 1. Escalating doses of KF were
administered i.v. weekly in two parallel arms. In one arm,
infusion length was first increased from 3 to 24 h while
maintaining dose at 530 lg/m2 (two transitional schedules of
6-h and 12-h were included), and once reached the 24-h
schedule, dose was increased while keeping the infusion
length. In the other arm, dose was escalated while main-
taining an infusion length of 3 h. Patients were allocated to
either arm according to slot availability. The study followed
a standard phase I dose-escalation design with cohorts of 36
patients treated at each dose level. The RD was defined as the
highest dose level at which less than 2 of 6 patients experi-
enced DLTs during the first 2 weeks of treatment. Once the
RD had been established, this cohort had to be expanded to
between 12 and 24 patients to obtain preliminary information
on the antitumor activity of the KF schedule.
Dose-limiting toxicities occurring during the first
2 weeks of treatment were defined as any of the following:
absolute neutrophil count \500/mm3 for [5 days or with
fever (C38.5 C); platelet count \25,000/mm3; any other
grade 3/4 non-hematological adverse event (AE) suspected
to be related to study drug(s) (except for nausea/vomiting
without prophylaxis and/or treatment, grade 3 transaminase
increase for \7 days, grade 3 gamma-glutamyltransferase
(GGT) increase, and hypersensitivity reactions); and any
Cancer Chemother Pharmacol (2013) 72:7583 77

Table 1 Dose escalation, distribution of patients, treatment cycles, and dose-limiting toxicities over the dose levels studied
Dose KF dose KF infusion No. of cycles No. of patients with Description of DLTs
level (lg/m2) length (hours) administered DLTs/no. of patients treated

Starting dose
1 530 3 38 0/3
Escalation from 3- to 24-h infusion
2 530 6 25 0/4
3 530 12 26 0/3
4 530 24 19 0/3
5 650 24 18 0/4
6 800 24 24 0/3
7 1,000 24 22 0/3
8 1,200 24 17 0/3
9 1,400 24 15 0/3
10 1,700 24 37 0/4
11 2,000 24 56 0/3
12 2,200 24 49 0/4
13 2,650 24 15 0/3
14 3,200 24 19 0/3
15 3,850 24 19 0/4
16 4,620 24 35 1/7 Grade 3 transaminase increase for C7 days.
17 5,540 24 16 0/3
18 6,650 (MTD) 24 34 3a/9 Grade 3 transaminase increase for C7 days.Grade 4
transaminase increase.Dose delay [2 weeks.b
Escalation at 3-h infusion
2 650 3 24 0/3
3 800 3 34 0/4
4 1,000 (RD) 3 121 During dose escalation: 1/6 Grade 4 transaminase increase.
During cohort expansion: 1/14 Grade 4 transaminase increase.
5 1,200 (MTD) 3 32 2c/6 Grade 4 transaminase increase.
6 1,400 3 25 2/4 Grade 4 transaminase increase.
The values in bold show how many patients had DLTs at each dose level
DLT dose-limiting toxicity, KF kahalalide F, MTD maximum tolerated dose, RD recommended dose
a
One of these DLTs was not found at the time of escalation
b
This dose delay lasted 3 weeks: The first 2 weeks of delay were due to KF-related grade 2 ALT/AST increase, while the third week of delay
was requested by the patient due to holidays
c
One of these DLTs was not reported as such during dose escalation, but was found after patient accrual had already started at the next cohort

delays in the administration of a subsequent dose of KF
exceeding 2 weeks due to AEs suspected to be drug-
related.
Patients continued receiving treatment as long as they
did not experience disease progression or unacceptable
toxicity, and they recovered from any previous toxicity;
that is, patients had to fulfill the same laboratory require-
ments for inclusion into the study. Otherwise, treatment
was delayed until recovery. If no recovery occurred within
2 weeks, the patients were withdrawn from the study
except in case of obvious clinical benefit. If any DLTs
appeared during the first 2 weeks, treatment was to be
interrupted until the DLTs had resolved and was to be
resumed at the next lowest dose level upon fulfillment of
the criteria for re-treatment. Patients were withdrawn from
the study if they required more than 2 dose reductions, and
there was no objective evidence of clinical benefit.
Patients were evaluable for toxicity if they had received
at least one KF infusion and for efficacy if they had
received at least one KF infusion and had evaluable lesions
as per the Response Evaluation Criteria In Solid Tumors
(RECIST, v.1.0) [12]. All toxicities were graded following
the National Cancer Institute Common Toxicity Criteria
(NCI-CTC, v. 2.0). Clinical and/or radiological

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assessments of the tumor according to the RECIST were Table 2 Baseline characteristics of the patients (n = 108)
done every 8 weeks. Total

Pharmacokinetic analyses Gender

Male 72 (67 %)
Blood samples (5 ml) for PK evaluation were collected at Female 36 (33 %)
predefined times at the first and second KF infusions, Median age (range) 60.0 (2786)
which varied depending on the length of infusion, from ECOG performance status
before infusion onset to up to 24 h after its end. Blood 0 60 (56 %)
samples were taken from the contralateral arm to the site of 1 44 (41 %)
KF administration. The samples were centrifuged at 2 4 (4 %)
2,5009g for 15 min to obtain the plasma fraction, which Primary tumor
was then stored at -20 C. Plasma concentrations of KF Colorectal adenocarcinoma 28 (26 %)
were determined using a validated high performance liquid Melanoma 19 (18 %)
chromatography system coupled with electrospray ioniza- Lung carcinoma 15 (14 %)
tion tandem mass spectrometry (HPLCMS/MS) method. Pancreas adenocarcinoma 6 (6 %)
The lower limit of quantification (LLOQ) was 1 ng/ml [13, Othera 40 (37 %)
14]. Complete concentrationtime profiles of KF were Previous anticancer therapy
analyzed by standard non-compartmental methods. Chemotherapy 106 (98 %)
Surgery 87 (81 %)
Radiotherapy 45 (42 %)
Results Otherb 19 (18 %)
ECOG Eastern Cooperative Oncology Group
Patient characteristics a
Prostate adenocarcinoma (n = 5), gastric adenocarcinoma, bladder
carcinoma, ovary adenocarcinoma, adenocarcinoma of unknown
A total of 108 patients were enrolled, and 106 of them were origin (n = 4 each), cholangiocarcinoma, breast carcinoma, oral
treated with KF (Table 2). Most patients (n = 104, 96 %) cavity squamous carcinoma (n = 3 each), renal carcinoma, leiomy-
had ECOG PS score 0 or 1 at baseline. The most frequent osarcoma (n = 2 each), hepatocarcinoma, pelvis squamous carci-
noma, penis carcinoma, testicle carcinoma, choriocarcinoma, and
tumor types were colorectal cancer (n = 28, 26 %), mel-
liposarcoma (n = 1 each)
anoma (n = 19, 18 %), NSCLC (n = 15, 14 %), and b
Biological therapy (n = 10), hormone therapy (n = 8) and gene
pancreatic cancer (n = 6, 6 %). All patients had metastatic therapy (n = 1)
(n = 93, 86 %) or locally advanced disease (n = 15,
14 %) at baseline. Most of them (n = 106, 98 %) had Dose-limiting toxicities, maximum tolerated dose,
previously received chemotherapy (median of 3 lines; and recommended dose
range 08). In addition, 87 patients (81 %) had undergone
surgery, 45 (42 %) had been given radiotherapy, and 19 All DLTs found during the 3-h infusion escalation were
(18 %) had received other anticancer therapies. asymptomatic and reversible grade 4 transaminase increa-
ses (Table 1). The first one occurred in one patient treated
Treatment at 1,000 lg/m2. No more DLTs were found upon expan-
sion of the cohort to 6 patients, and dose escalation was
A total of 720 cycles were administered at 23 different dose resumed. None of the first 3 patients treated at 1,200 lg/m2
levels, each cycle lasting 1 week: 274 cycles at 6 dose had DLTs, and hence, dose was again escalated. DLTs
levels as 3-h infusion (including 38 cycles at the starting occurred in 2 of 4 patients treated at 1,400 lg/m2. As a
dose of 530 lg/m2), 25 cycles at one dose level as 6-h result, further dose escalation was discontinued, and the
infusion (transitional schedule), 26 cycles at one dose level 1,200 lg/m2 cohort was expanded. However, 2 out of 6
as 12-h infusion (transitional schedule), and 395 cycles at patients treated at this dose level had DLTs, and therefore,
15 dose levels as 24-h infusion (Table 1). The median 1,200 lg/m2 was considered the MTD for the 3-h schedule.
number of cycles administered per patient was 6.5 (range Consequently, 14 additional patients (for a total of 20)
126 cycles) for the 3-h schedule, 8.0 (range 18 cycles) were evaluated at the immediately lowest dose level
for the 6-h schedule, and 6.0 (range 218 and 133) for the (1,000 lg/m2), and one DLT was found. This dose level
12-h and 24-h schedules, respectively. was established as the RD for the 3-h weekly schedule.

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No DLTs occurred in the first 15 dose levels during
escalation from 3 to 12 h, but at the 24-h infusion
(Table 1), one of the first 3 patients treated at 4,620 lg/m2
had a DLT (grade 3 transaminase increase for C7 days)
and the cohort was expanded. No further patients had
DLTs, and hence, dose escalation was resumed. DLTs
(grade 3 transaminase increase for C7 days, grade 4
transaminase increase, and dose delay [2 weeks) occurred
in 3 of 9 patients treated at 6,650 lg/m2 as 24-h infusion;
one of these DLTs was not detected at the time of esca-
lation. Hence, the dose level of 6,650 lg/m2 was estab-
lished as the MTD for the 24-h schedule. No RD could be
confirmed for this schedule because the number of patients
who were treated at the dose level immediately below the
MTD (i.e., 5,540 lg/m2) was too low (3 instead of the 6
required by the study protocol, as the study was stopped
following the sponsors decision to search for a synthetic
KF analogue). All patients with DLTs in this escalation
arm recovered from these toxicities.
Toxicity profile
All 106 treated patients were evaluable for safety. Most
treatment-related AEs found with all KF infusion lengths
were mild or moderate, with paresthesia, fatigue, pruritus,
rash, nausea, and vomiting as the most common (Table 3).
Of note, the incidence of most of these AEs decreased
when the infusion length increased from 3 to 24 h. Severe
treatment-related AEs were grade 3 only and occurred in 2
patients: hypersensitivity in one patient treated at 800 lg/
m2 as 3-h infusion and fatigue in one patient treated at
530 lg/m2 as 12-h infusion. Two patients treated with the
3-h schedule discontinued due to drug-related events: one
due to grade 2 rash and one due to grade 3 hypersensitivity;
the latter occurred prior to the implementation of the pre-
medication with H1 and H2 receptor antagonists for all
patients receiving KF at infusion times shorter than 24 h.
No discontinuations due to drug-related AEs occurred at
the other schedules. In addition, no dose delays or reduc-
tions at any schedule were due to related AEs.
Regardless of causality, grade 3/4 hematological or
biochemical abnormalities only occurred in patients treated
with the 3-h or 24-h schedules (Table 3). No hematological
abnormalities reached grade 4, while grade 3 lymphopenia
was found in 13 % of patients in the 3-h schedule and 11 %
of patients in the 24-h schedule, and grade 3 anemia was
found in 5 % of patients in the 24-h schedule. Grade 3/4
transaminase increases were more common in the 3-h
schedule than in the 24-h schedule: 38 % versus 15 %
(ALT increase) and 35 % versus 11 % (AST increase).
Most of these episodes occurred in patients treated at the
highest dose levels (C1,000 lg/m2 for the 3-h infusion or
C4,620 lg/m2 for the 24-h infusion). They were also
79
transient and reversible, lasting for a median of 6 days
(113 days) with the 3-h schedule and 6.5 days (18 days)
with the 24-h schedule. The incidence of grade 3/4 GGT
increase was similar in the two schedules (25 % of patients
in the 3-h schedule and 27 % of patients in the 24-h
schedule). Of note, the 4 cases of grade 4 GGT increase
found in both schedules occurred in patients who already
had grade 3/4 GGT increase at baseline (n = 2) or were
showing evidence for clinical progression of hepatocarci-
noma (n = 1) or pancreatic cancer (n = 1). A total of 4
patients had grade 3/4 total bilirubin increase: one grade 4
episode with the 3-h schedule and three grade 3 episodes
with the 24-h schedule. All episodes were concomitant
with grade 3/4 increases in plasma levels of transaminases,
AP and/or GGT levels, and occurred in patients with
cholangiocarcinoma (n = 2) or with other tumor types that
had metastatized to the liver (n = 2). Other severe bio-
chemical abnormalities (grade 3 AP increase) were less
common and had no effects on treatment.
Efficacy
A total of 93 patients at all dose levels were evaluable for
response. Ten patients had stable disease (SD) as best
response: 3 treated with the 3-h schedule (2 at the RD of
1,000 lg/m2 and one at 1,400 lg/m2) and 7 treated with
the 24-h schedule (at doses ranging from 800 to 6,650 lg/
m2) (Table 4). Of note, 8 of these disease stabilizations
were achieved in patients who had been treated with at
least 2 prior chemotherapy lines. In 8 patients, disease
stabilization lasted for C3 months. Their tumor types
comprised NSCLC and colorectal cancer (n = 1 each) with
the 3-h schedule, and NSCLC (n = 2), colorectal cancer,
hepatocarcinoma, bladder cancer, and cholangiocarcinoma
(n = 1 each) with the 24-h schedule.
Pharmacokinetics
PK data were available from 103 patients in Cycle 1 and 93
patients in Cycle 2. No clear trend was found in the dif-
ferences between the PK parameters after the first and
second KF infusions. No major deviations from linearity
were detected when the area under the curve (AUC) and
Cmax values of the 3- and 24-h schedules were analyzed
independently (Table 5). At the RD of 1,000 lg/m2 given
as 3-h infusion, the mean AUC was 159.6 h*ng/ml and the
mean Cmax was 56.3 ng/ml after the first administration of
KF. At the MTD of 6,650 lg/m2 given as 24-h infusion,
the mean AUC was 2,404.2 h*ng/ml and the mean Cmax
was 162.4 ng/ml.
The half-life (t), total body clearance (CL), and vol-
ume of distribution at steady state (Vss) showed moderate
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Table 3 Treatment-related adverse events and laboratory abnormalities at all dose levels with the 3-h and 24-h schedules (at least 10 % of
patients)
KF infusion length
3-h (n = 40) 24-h (n = 59)
NCI-CTC grade NCI-CTC grade
12 3 4 12 3 4

Treatment-related adverse eventsa

Fatigue 8 (20 %) 7 (12 %)
Nausea 6 (15 %) 4 (7 %)
Paresthesia 9 (23 %) 6 (10 %)
Pruritus 12 (29 %) 9 (15 %)
Rash 4 (10 %) 2 (3 %)
Vomiting 5 (13 %) 2 (3 %)
Hematological abnormalitiesb
Anemia 29 (73 %) 39 (66 %) 3 (5 %)
Leukopenia 9 (23 %) 5 (9 %)
Lymphopenia 22 (55 %) 5 (13 %) 24 (41 %) 6 (11 %)
Neutropenia 5 (13 %) 2 (3 %)
Thrombocytopenia 10 (25 %) 13 (22 %)
Biochemical abnormalitiesb
ALT increase 13 (33 %) 11 (28 %) 4 (10 %) 32 (54 %) 7 (12 %) 2 (3 %)
AP increase 23 (58 %) 1 (3 %) 34 (58 %) 5 (9 %)
AST increase 16 (40 %) 8 (20 %) 6 (15 %) 41 (70 %) 5 (9 %) 1 (2 %)
Bilirubin increase 8 (20 %) 1 (3 %) 11 (19 %) 3 (5 %)
Creatinine increase 12 (30 %) 13 (22 %)
GGT increase 22 (55 %) 8 (20 %) 2 (5 %) 25 (42 %) 14 (24 %) 2 (3 %)
Data shown are number (%) of patients
KF Kahalalide F, NCI-CTC National Cancer Institute Common Toxicity Criteria
a
Includes adverse events with an unknown relationship with the treatment, according to the investigator
b
Regardless of relationship with the treatment

inter- and intrapatient variability in the 3-h infusion sche-
dule, whereas variability in the 24-h infusion was moderate
for CL and high or very high for both t and Vss. Of note, a
significant correlation was found between Cmax values, and
the peak ALT value was measured after administration of
the first KF infusion; no such correlation was found
between AUC and peak ALT values.
Discussion
This phase I clinical trial evaluated the administration of
weekly i.v. KF at infusion times longer than 1 h in patients
with advanced solid tumors. Two dose escalations were
conducted in parallel: one increased the KF dose while
maintaining the infusion time at 3 h, while the other one
first increased the infusion time from 3 to 24 h, and then
increased the KF dose at an infusion time of 24 h. The
MTDs established for these escalations (1,200 lg/m2 for
3-h infusion and 6,650 lg/m2 for 24-h infusion) were
greater than the MTD of 800 lg/m2 established for weekly
KF when given as a 1-h infusion [11]. A dose of 1,000 lg/
m2 was established as the RD for phase II trials with the
3-h schedule; no recommended dose could be confirmed
for the 24-h schedule. The majority of the DLTs found with
the 3-h and the 24-h schedules consisted of grade 3/4
transient transaminase increases, which was in accordance
with the findings of previous phase I trials with single-
agent KF [10, 11].
Both the 3-h and the 24-h schedules were generally well
tolerated and associated with manageable, predictable, and
reversible toxicities. Most treatment-related AEs in these
schedules were mild or moderate, and the only one to reach
grade 3 severity was one episode of hypersensitivity that
occurred prior to the implementation of specific guidelines
for the management of these cases. Regardless of causality,
severe hematological abnormalities were grade 3 lympho-
penia, which occurred at a similar frequency in both

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Table 4 Characteristics of patients with evidence of antitumor activity

Dose level Gender Age PS Tumor type Prior CT Last Best overall TTP OS
(lg/m2) (years) lines cycle response (mo) (mo)

3-h schedule
1,000 Female 65 1 Ovary adenocarcinoma 3 6 SD 1.61 1.81a
Male 72 1 Lung carcinoma 4 12 SD 3.22 4.73
1,400 Male 59 1 Colorectal adenocarcinoma 4 16 SD 3.45 9.86
24-h schedule
800 Male 51 0 Lung carcinoma 3 14 SD 3.48 4.60
1,700 Female 39 1 Colorectal adenocarcinoma 2 16 SD 3.91 4.11a
2,000 Male 74 0 Lung carcinoma 2 32 SD 8.78 18.73
Male 59 Hepatocarcinoma 16 SD 3.52 3.68a
2,200 Male 59 0 Bladder carcinoma 3 33 SD 9.63 9.63a
4,620 Male 61 0 Cholangiocarcinoma 1 10 SD 3.48 3.68a
6,650 Female 47 1 Ovary adenocarcinoma 5 6 SD 1.87 1.87a
CT chemotherapy, OS overall survival, PS performance status, SD stable disease, TTP time to progression
a
These patients were still alive at the end of study follow-up

Table 5 Mean area under the curve (AUC) and maximum plasma concentration (Cmax) values by dose level after the first treatment infusion,
grouped by infusion length
Dose level Infusion length in hours
(lg/m2)
3h 6h 12 h 24 h
n AUC Cmax n AUC Cmax n AUC Cmax n AUC Cmax
(h*ng/ml) (ng/ml) (h*ng/ml) (ng/ml) (h*ng/ml) (ng/ml) (h*ng/ml) (ng/ml)

530 3 89.1 (7.2) 32.3 (2.6) 4 120.3 (74.5) 14.8 (5.3) 3 71.5 (7.4) 7.3 (0.6) 2 143.1 (84.7) 7.7 (0.2)
650 3 106.1 (60.1) 37.7 (19.9) 3 135.6 (54.7) 11.5 (7.4)
800 4 127.9 (21.0) 46.5 (6.4) 3 107.2 (23.2) 5.4 (0.8)
1,000 20 159.6 (44.7) 56.3 (15.9) 3 184.8 (86.6) 8.6 (2.7)
1,200 6 191.3 (66.0) 66.9 (17.9) 3 157.6 (21.1) 11.0 (5.4)
1,400 4 193.7 (72.8) 65.3 (19.0) 3 219.4 (49.5) 11.5 (3.6)
1,700 3 200.9 (66.1) 11.4 (3.7)
2,000 3 324.1 (27.0) 23.5 (12.5)
2,200 3 207.7 (3.8) 10.5 (1.2)
2,650 3 446.4 (76.0) 25.5 (2.1)
3,200 3 580.8 (165.3) 30.3 (2.5)
3,850 4 604.8 (201.8) 34.2 (7.4)
4,620 7 698.7 (129.7) 39.2 (13.6)
5,540 3 1,038.9 (632.6) 51.7 (34.2)
6,650 8 2,404.2 (2,792.5) 162.4 (256.9)
Values are expressed as mean (SDev)
One patient received an incorrect drug dose and has not been included in this table
AUC area under the curve, Cmax maximum plasma concentration, SDev standard deviation

schedules, and anemia, which involved only 5 % of treated
patients in the 24-h schedule. Among the biochemical
abnormalities, all grade 3/4 transaminase increases found
in either schedule were related to treatment but were
transient and asymptomatic. No cases of treatment-related
liver dysfunction were reported. Transitory, non-clinically
relevant transaminases increases were also found as a
common laboratory abnormality in a phase II trial evalu-
ating the 1-h weekly KF schedule at the RD of 650 lg/m2
in patients with advanced malignant melanoma [15]. These

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abnormalities were more common with the 3-h schedule
compared to the 24-h schedule, but while they caused most
treatment-related dose delays and reductions in either
schedule, only 2 patients treated with the 24-h schedule
were withdrawn because of them.
Overall, the PK profiles of weekly KF given as 3-h or
24-h infusions agree with those reported for the other
single-agent KF schedules tested to date [10, 11]. All
profiles are characterized by linear kinetics for AUC val-
ues, a narrow volume of distribution and a short terminal
half-life. Inter- and intrapatient variability of clearance was
moderate in the 3-h and 24-h schedules. The AUC values
found in the present study for weekly KF at 8001,200 lg/
m2 given as 3-h and 24-h infusions were lower than those
found in a previous phase I study for these same dose levels
given as 1-h infusions [11]. This might be due to the
interference of Cremophor, a nonionic surfactant used as
formulation vehicle of KF that is known to induce the
formation of micellae that sequester drugs, thereby
decreasing their free fraction and causing kinetic pseudo-
nonlinearity. This could also explain the higher Vss value
found in this phase I study at longer infusion times.
The short half-life and narrow distribution observed in
the PK profiles of single-agent KF schedules suggest that
the compound has limited extravascular tissue binding and
is rapidly eliminated from the system. Although the exact
metabolism of KF has not been completely elucidated yet,
renal elimination is not an extensive route of elimination
(\2 % of recovery in 24-h urine). In addition, experiments
with human liver microsomes have not been conclusive, as
no biotransformation has been observed. There probably is
some minor chemical degradation to the product kahalalide
G, observed in incubations with buffered solutions,
although kahalalide G could not be distinguished in pooled
human plasma due to endogenous interference [16, 17].
Prolonged disease stabilizations occurred in 8 heavily
pretreated patients with NSCLC (n = 3), colorectal cancer
(n = 2), hepatocarcinoma, bladder cancer, and cholangio-
carcinoma (n = 1 each). Three of these tumor types (lung
cancer, hepatocarcinoma, and colon cancer) have already
been shown to be sensitive to KF by in vitro studies [5, 18]
or in a previous phase I trial [11].
In conclusion, this study shows that administration of
weekly KF at prolonged infusion times is feasible, with 3-h
and 24-h infusion times showing tolerable safety profiles.
The DLTs found for both schedules consist of asymp-
tomatic, reversible, and transient transaminase increases. A
dose of 1,000 lg/m2 was established as the RD for further
development with the 3-h schedule; no such dose could be
confirmed for the 24-h infusion schedule. Tumor types that
may be adequate for future exploratory studies with the
weekly 3-h schedule comprise non-small cell lung cancer
123
Cancer Chemother Pharmacol (2013) 72:7583
and colon cancer. Clinical trials are currently ongoing with
the synthetic KF analogue PM02734.
Conflict of interest Josep Tabernero has participated in advisory
boards of Pharma Mar, and his institution has received research
funding from Pharma Mar to conduct clinical trials. Cinthya Coro-
nado, Arturo Soto Matos-Pita, Bernardo Miguel-Lillo, Martin Cullell-
Young, and Jorge Luis Iglesias Dios are currently PharmaMar
employees. All other authors declare no conflicts of interest.
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