Robles et al. Orphanet Journal of Rare Diseases (2016) 11:128 DOI 10.1186/s13023-016-0517-9 RESEARCH Open Access Everolimus safety and efficacy for renal angiomyolipomas associated with tuberous sclerosis complex: a Spanish expanded access trial Nicolás Roberto Robles1, Ramón Peces2, Álvaro Gómez-Ferrer3, Felipe Villacampa4, Jose Luis Álvarez-Ossorio5, Pedro Pérez-Segura6, Juan Morote7, Bernardo Herrera-Imbroda8, Javier Nieto9, Joaquín Carballido10, Urbano Anido11, Marian Valero12, Cristina Meseguer12 and Roser Torra13* Abstract Background: Renal angiomyolipomas (AML) are usual manifestations of tuberous sclerosis complex (TSC) that may cause aneurism-related haemorrhages and renal impairment. Everolimus has emerged as an alternative to surgery/ embolization. We provide further insight into everolimus safety and efficacy for TSC-related AML. Methods: This was a Spanish expanded access trial including patients aged ≥18 years with TSC-related AML. They received 10 mg everolimus once daily until AML progression, unacceptable toxicity, death/withdrawal, commercialisation for TSC-related AML, or 1 year after first patient enrolment. The primary outcome was dose-limiting safety according to grade 3/4 adverse events, serious adverse events, or adverse events leading to treatment modification. Secondary outcomes included overall safety and efficacy. Results: Nineteen patients were enrolled and received everolimus for a median of 6.6 (5.3–10.9) months. Eleven (57.9 %) remained on 10 mg/day throughout the study and eight (42.1 %) required treatment modifications due to adverse events; none permanently discontinued treatment. Adverse events were overall grade 1/2 and most frequently included aphthous stomatitis/mucosal inflammation, hypercholesterolaemia/hypertriglyceridaemia, urinary tract infection, hypertension, dermatitis acneiform, and insomnia. Four (21.1 %) patients experienced grade 3 adverse events, none was grade 4, and only one (5.3 %) was serious (pneumonia). AML volume was reduced ≥30 % in 11 (57.9 %) patients and ≥50 % in 9 (47.4 %); none progressed. Right and left kidney sizes decreased in 16 and 14 patients, respectively. Conclusions: These findings support the benefit of everolimus for renal AML due to a manageable safety profile accompanied by reduced AML and kidney volumes. Trial registration: EudraCT number 2012-005397-63; date of registration 22 Nov 2012. Keywords: Angiomyolipoma, Everolimus, Safety, Tuberous sclerosis complex * Correspondence: rtorra@fundacio-puigvert.es 13 Inherited Renal Diseases, Department of Nephrology, Fundació Puigvert, REDINREN, IIB Sant Pau, Universitat Autónoma de Barcelona, Cartagena, 340-350, 08025 Barcelona, Spain Full list of author information is available at the end of the article © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Robles et al. Orphanet Journal of Rare Diseases (2016) 11:128 Page 2 of 9 Background safety and efficacy of everolimus for the management of Tuberous sclerosis complex (TSC) is an autosomal dom- renal AML associated with TSC in Spain. inant genetic disorder usually caused by mutations in either the TSC1 or TSC2 genes [1, 2] and which affects Methods one in about 8000 to 12,900 individuals [3, 4]. These This trial was conducted in accordance with the World mutations spearhead mammalian target of rapamycin Medical Association Declaration of Helsinki, all its (mTOR) activation, leading to uncontrolled cellular amendments, and national regulations. It was approved by proliferation [5]. The disease is characterized by neuro- the ethics committee of Fundació Puigvert (Barcelona, cognitive deficits and growth of non-malignant tumours Spain) and all patients gave their written informed consent called hamartomas in several body locations, including prior to any study procedure. renal angiomyolipomas (AML) in up to 80 % of patients along with other manifestations [6]. These AML are Patient population mesenchymal tumours composed of abnormal blood This study included all patients meeting selection cri- vessels, immature smooth muscle cells and adipose teria who agreed to participate and were consecutively tissue [7]. They usually appear in childhood and their recruited between May 2013 and May 2014. The main progressive enlargement leads to a high risk of bleeding inclusion criteria comprised patients aged 18 years or and may sometimes encroach on the renal parenchyma older, with at least one renal AML of 3 cm or larger in causing renal failure [7]. Unlike sporadic renal AML, its longest diameter as per computed tomography (CT) TSC-related AML tends to be larger, multiple, and at or magnetic resonance imaging (MRI), and a definite higher risk of bleeding [8]. The main goals of treating diagnosis of TSC. This diagnosis was based on the mo- patients with renal AML are preserving kidney function dified Gomez criteria [19, 20]. Patients whose AML and preventing complications such as haemorrhages. required surgery at enrolment were excluded, as well as Surgical procedures or embolization has been used to those with AML-related bleeding or embolisation during manage large, symptomatic, and/or bleeding AMLs, but the 6 months prior to enrolment. Other exclusion mTOR inhibitors have now emerged as a non-invasive criteria mainly included previous history of heart attack, treatment alternative [9]. angina pectoris, haemorrhagic stroke related to athero- Everolimus is an orally bioavailable mTOR inhibitor sclerosis, impaired lung functioning, organ transpla- that induces cell cycle arrest, reduces cell proliferation, ntation, or any surgery within the 2 months prior to and prompts angiogenesis regression, contributing to enrolment, and also the presence of significant haema- suppress the enlargement of tumours and promoting tological/hepatic abnormality, serum creatinine levels their regression [10, 11]. Everolimus has demonstrated higher than 1.5 times the upper limit of normal, haemor- clinical activity across a variety of tumours, leading to its rhagic diathesis or treatment with vitamin K antagonists approval for malignancies such as hormone receptor- (except for low-dose warfarin), uncontrolled hyperlipid- positive advanced breast cancer, neuroendocrine tu- aemia/diabetes, other uncontrolled/severe disease that mours of pancreatic origin and renal cell carcinoma might cause unacceptable safety risks, or any ongoing/ [12]. The EXIST-2 phase III trial investigated the use of active infection (except for hepatitis B/C virus infection) everolimus for renal AML associated with TSC [13]. It at study enrolment. was a randomized, double-blind, placebo-controlled trial that demonstrated the efficacy of everolimus administra- Study design and treatment tion to adult patients with TSC-related AML, showing This was an open-label, single-arm, phase IIIb, expanded that over half of patients experienced at least a 50 % re- access trial carried out at 12 Spanish hospitals. Screening duction in AML volume after just 6 months of treatment and baseline assessments were conducted over the 21 days [13]. The efficacy and manageable safety profile seen in prior to the first dose of everolimus (Fig. 1). Eligible patients this trial were consistent with those observed in its sub- then started once-daily oral administration of everolimus at sequent extension phase [14]. In addition, everolimus a dose of 10 mg/day after signing the informed consent. safety appeared to be similar to that previously reported Everolimus was administered until AML progression, in other TSC populations [15–18] and did not give rise occurrence of unacceptable toxicity according to investiga- to safety concerns with regard to its use for different tor’s criteria, patient death or withdrawal for any reason. solid tumours [11]. This positive benefit/risk balance Another criterion to stop the trial was everolimus commer- supported the use of everolimus for TSC-related renal cialisation for TSC-related AML in Spain, or 1 year after AML and was the basis for requesting the European first patient enrolment; the latter was what occurred first. Medicines Agency’s authorization for this indication. Treatment modifications were determined clinically on the In light of the above, we decided to conduct an ex- basis of safety findings (i.e. according to the grade of panded access trial to provide further insight into the adverse events as per the Common Terminology Criteria Robles et al. Orphanet Journal of Rare Diseases (2016) 11:128 Page 3 of 9 Screening/baseline Everolimus administration Post-treatment safety assessments (until progression, unacceptable toxicity, death, follow-up (≤ 21 days pre-treatment) withdrawal, everolimus commercialisation for this (28 days post-treatment) condition, or one year after first patient enrolment) Informed consent Study treatment administration Concomitant medication Selection criteria Clinical examination Adverse events Demographics Clinical laboratory analyses Medical history Kidney CT/MRI (months 3, 6, 12/end of treatment) Comorbidities Concomitant medication Clinical examination Adverse events Clinical laboratory analyses Kidney CT/MRI Concomitant medication Fig. 1 Overall flow chart and main study assessments. Abbreviations: CT computed tomography, MRI magnetic resonance imaging for Adverse Events (CTCAE) of the National Cancer Insti- confirmed in a second scan performed approximately tute version 4.03 [21]), including dose adjustments, tempor- 12 weeks later (no sooner than 8 weeks later), and in the ary treatment interruptions or permanent treatment absence of new lesions with longest diameter ≥1 cm, kid- discontinuation. Initial doses of 10 mg/day could be low- ney volume increase >20 % from nadir, and AML-related ered to 5 mg/day (dosing level −1) or even to 5 mg/every grade ≥2 bleeding or need for embolisation/surgery. other day (dosing level −2). Radiologic progression was defined as ≥25 % increase Prophylactic antiviral treatment was recommended in from nadir in the sum of volumes of all target lesions and/ patients with detectable hepatitis B virus DNA or surface or ≥20 % increase from nadir in the volume of either antigen, although there were none. The use of antiprolif- kidney with a value greater than baseline, appearance erative agents or investigational drugs other than the of new lesions with longest diameter ≥1 cm, and/or study treatment was prohibited. Concomitant use of AML-related grade ≥2 bleeding or need for embolisa- moderate/strong inhibitors or strong inducers of cyto- tion/surgery. Volume of each kidney was measured by chrome P450 3A4 was to be avoided, as well as the use CT/MRI to assess changes in non-target/non-measur- of p-glycoprotein inhibitors and attenuated vaccines. able AML lesions. There were no further restrictions with regard to con- comitant medication. Statistical analysis Toxicity of study treatment was continuously assessed The primary outcome was dose-limiting safety according according to adverse events reported in every monthly to the incidence of grade 3/4 adverse events, serious ad- follow-up until 28 days post-treatment. All adverse verse events, and those leading to changes in the admin- events were coded using the Medical Dictionary for istration of everolimus (i.e. dose change, interruption, or Regulatory Activities (MedDRA) preferred term and discontinuation). Secondary outcomes included the over- graded as per the CTCAE of the National Cancer Insti- all safety of everolimus based on the incidence of any- tute version 4.03 [21]. Their relationship with everolimus grade adverse events and its efficacy according to the was categorized as non-related, unlikely, possibly, likely, AML response rate. Descriptive analyses of patient char- or definitively related. AML response/progression was acteristics and outcomes were conducted, including cen- assessed by kidney CT/MRI. Local radiologists assessed tral tendency and dispersion (mean ± standard deviation measurable (longest diameter ≥1 cm) and non-measurable [SD], or median [interquartile range, IQR]) for quantita- (longest diameter <1 cm) lesions at baseline, and at tive variables, and frequency distribution (absolute fre- months 3, 6, and 12/end of treatment; for each patient, quencies and valid percentages) for qualitative variables. the same kidney imaging modality was used throughout Missing data were not considered in the analyses, which the study. Radiologic response was defined as ≥50 % re- were performed with the Statistical Package for the duction from baseline in the sum of volumes of all target Social Sciences version 19 (SPSS Inc, Chicago, USA) and lesions (≤5 largest lesions with longest diameter ≥1 cm), R version 2.15.0 (The R Foundation, Vienna, Austria). Robles et al. Orphanet Journal of Rare Diseases (2016) 11:128 Page 4 of 9 Results target renal AML lesions of 260.0 (127.8–322.2) cm3; Patient characteristics volumes of right and left kidneys reached 329.4 (193.0– A total of 20 patients were assessed for eligibility, one of 979.7) cm3 and 299.0 (184.2–404.7) cm3, respectively. whom was considered a screening failure as a result of suf- fering from an uncontrolled/severe disease that might have Everolimus exposure caused unacceptable safety risks. Therefore, 19 patients The median (IQR) duration of everolimus exposure was were finally enrolled and received the study treatment. 6.6 (5.3–10.9) months. The weighted mean (±SD) dose Their median (IQR) age was 38.0 (29.0–43.0) years was 9.1 ± 1.4 mg/day and the mean (±SD) accumulated and more than a half (68.4 %) were females (Table 1). dose reached 2123.0 ± 995.2 mg. They showed a median (IQR) sum of volumes of all Eleven (57.9 %) patients received 10 mg/day of everoli- mus over the whole study duration. The remaining eight Table 1 Baseline patient characteristics (N = 19) (42.1 %) patients required at least a dose reduction or Patient characteristics Value temporary interruption of treatment. No patient per- manently discontinued the study treatment. Age (years), median (IQR) 38.0 (29.0–43.0) Sex, n (%) Safety outcomes Female 13 (68.4) Primary safety outcome Male 6 (31.6) A total of four (21.1 %) patients experienced five grade 3 Race, n (%) adverse events, all of which were non-serious (Table 2). White 19 (100) They included an increase in transaminases likely related to everolimus that led to the temporary interruption of Main comorbidities, n (%) a treatment, hypertriglyceridaemia likely related to everoli- Hypertension 3 (15.8) mus that required no therapeutic action, hypertriglyceri- Asthma 2 (10.5) daemia definitively related to everolimus that required Hypercholesterolaemia 2 (10.5) concomitant medication, hypertension likely related to Major features for TSC diagnosis, n (%)a everolimus that also required concomitant medication, Renal AML 19 (100) and mucosal inflammation definitively related to everoli- mus that led to the temporary interruption of treatment. Facial angiofibromas/forehead plaque 15 (79.0) No grade 4 adverse event was reported. Cortical tuber 10 (52.6) Only one (5.3 %) patient reported a serious adverse Hypomelanotic macules (≥3) 7 (36.8) event, which was a grade 2 pneumonia considered de- Subependymal nodule 7 (36.8) finitively related to everolimus and that led to the Non-traumatic ungual/periungual fibroma 4 (21.1) temporary interruption of treatment (Table 2). Single/multiple cardiac rhabdomyoma 4 (21.1) Treatment modifications resulting from adverse events were reported in eight (42.1 %) patients: dose reductions Lymphangiomyomatosis 3 (15.8) Connective tissue nevus 2 (10.5) Table 2 Dose-limiting safety (N = 19) Minor features for TSC diagnosis, n (%)a Outcome n (%) Multiple renal cysts 11 (57.9) Patients with grade 3/4 adverse events 4 (21.1)a Multiple randomly distributed pits 3 (15.8) Patients with serious adverse events 1 (5.3)b in dental enamel Patients with adverse events leading to treatment 8 (42.1) Bone cysts 3 (15.8) modification: Non-renal hamartoma 2 (10.5) Adverse events leading to dose reduction 3 (15.8) “Confetti” skin lesions 1 (5.26) Adverse events leading to temporary treatment 3 (15.8) Sum of volumes of target renal AML 260.0 (127.8–322.2) interruption lesions (cm3), median (IQR) Adverse events leading to dose reductions and temporary 2 (10.5) Volume of right kidney (cm3), median (IQR) 329.4 (193.0–979.7)b treatment interruption Volume of left kidney (cm3), median (IQR) 299.0 (184.2–404.7)c Adverse events leading to permanent treatment 0 (0.0) withdrawal Abbreviations: AML angiomyolipoma, IQL interquartile range, SD standard deviation, TSC tuberous sclerosis complex All adverse events were graded as per the Common Terminology Criteria for a Multiple response variable Adverse Events (CTCAE) of the National Cancer Institute (version 4.03) b a One patient had previously undergone nephrectomy of right kidney and two Four patients experienced five grade 3 adverse events (i.e. transaminases had technical problems for renal volume assessment; N = 16 increased n = 1, hypertriglyceridaemia n = 2, hypertension n = 1, mucosal c Three patients had previously undergone nephrectomy of left kidney and one inflammation n = 1); no grade 4 adverse event was reported had technical problems for renal volume assessment; N = 15 b The only serious adverse event was grade 2 pneumonia Robles et al. Orphanet Journal of Rare Diseases (2016) 11:128 Page 5 of 9 in three (15.8 %), temporary treatment interruptions in initiation to the response assessment of 3.3 (3.0–6.2) another three (15.8 %), and both dose reduction and months. Ten (52.6 %) patients remained stable (i.e. nei- temporary treatment interruption in two (10.5 %) ther radiologic response nor progression) and none (Table 2). The reasons for dose reductions included showed AML progression. menorrhagia, anaemia, hypercholesterolaemia, hypertri- The sum of volumes of all target AML lesions de- glyceridaemia, hypertension, and investigator’s decision creased in 16 (84.2 %) patients, including ≥30 % reduc- due to accumulated adverse events rather than a specific tion from baseline in 11 (57.9 %) patients and ≥50 % in event. The reasons for temporary treatment interruption nine (47.4 %) patients; the proportion of patients achiev- encompassed gamma-glutamyltransferase increased, pneu- ing ≥30 % and ≥50 % reduction from baseline in each monia, polypectomy, herpes zoster, mucosal inflammation, study visit is summarized in Fig. 2. Only three (15.8 %) transaminases increased, and erythema. patients report increased volumes, which were lower than 15 % in all cases. Secondary safety outcome The volume of right kidney was reduced in 16 pa- All patients showed at least one of the 158 reported tients; no data was available on right kidney volume in adverse events, regardless of relationship to study drug three patients (two due to technical problems and one (adverse events of any cause). They were mostly grade 1/ due to nephrectomy). The volume of left kidney de- 2 in severity and most frequently included (>25 % of creased in 14 patients and only one patient showed patients): aphthous stomatitis, hypercholesterolaemia, increased left kidney volume, which was lower than hypertriglyceridaemia, urinary tract infection, mucosal 20 %; no data was available in four patients (one due to inflammation, hypertension, dermatitis acneiform, and technical problems and three due to nephrectomy). insomnia (Table 3). Overall, 18 (94.7 %) patients reported 106 adverse Discussion events suspected to be everolimus related (i.e. possibly, This phase IIIb expanded access trial supports the bene- likely, or definitively related). They were mostly grade 1/ fit of everolimus administration to adult patients with 2 and most commonly included (>25 % of patients): TSC-related renal AML, due to a manageable safety aphthous stomatitis (n = 11, 57.9 %), hypercholesterol- profile accompanied by reduced AML lesions and kidney aemia (n = 11; 57.9 %, grade 1 in five patients and volumes. The overall safety profile was as expected grade 2 in six patients), hypertriglyceridaemia (n = 8; according to previously described adverse events experi- 42.1 %), urinary tract infection (n = 6; 31.6 %), muco- enced by patients with TSC during everolimus admi- sal inflammation (n = 7; 36.8 %), and dermatitis acnei- nistration [13–18]. Oral mucosal inflammation with/ form (n = 5; 26.3 %). without aphthae, hypercholesterolaemia, hypertriglyceri- A total of 45 infections were observed in 14 (73.7 %) daemia and infections such as those of the urinary tract patients, which were grade 1/2 and affected the oral were reported among the most frequent adverse events. cavity (n = 16), respiratory tract (n = 12), urinary tract These were mostly mild to moderate and could be (n = 8), skin (n = 7), and eyes (n = 2). Only two renal appropriately managed without everolimus discontinu- adverse events were reported, including grade 1 pro- ation, with decreased dose and/or adjunctive therapy. teinuria (i.e. 1+ proteinuria; urinary protein <1.0 g/ Indeed, initial everolimus administration was maintained 24 h) (n = 1) and polyuria (n = 1); neither haemor- in nearly 60 % of patients and it could be continued in rhage of renal AML nor increase of creatinine levels the remaining patients after dose reductions and/or was reported. Amenorrhoea was reported in three pa- transient interruptions. Although the occurrence of tients, which accounted for 27.3 % of 11 pre-menopausal grade 3/4 adverse events might have jeopardized the females and was grade 1 in all cases (i.e. intermittent men- administration of everolimus, only five grade 3 and no ses with skipped menses for no more than 1 to 3 months); grade 4 events were reported over the study duration it was recovered in two patients and remained ongoing at and most of them could be appropriately managed with the end of the study in another, who developed it 1 month concomitant medication or just observation; only two before the study completion. Regarding hypercholesterol- required temporary treatment interruptions. Furthermore, aemia: no action was taken in two patients (grade 1), there only one patient reported a serious adverse event, a case was no study treatment interruption/discontinuation in of pneumonia that also led to temporary treatment inter- any patient, and a concomitant treatment was reported in ruption. These results are consistent with data reported by nine patients. the EXIST-2 trial on the administration of everolimus to adult patients with TSC-related AML [13, 14] and other Efficacy outcomes trials including the EXIST-1 on everolimus administration Nine (47.4 %) patients reported radiologic response of to adult/child patients with other TSC-related tumours renal AML, with a median (IQR) time from everolimus [15–18]. Adverse events have usually been reported in Robles et al. Orphanet Journal of Rare Diseases (2016) 11:128 Page 6 of 9 Table 3 Adverse events of any cause experienced by ≥10 % patients over the study (N = 19) Adverse event, n (%) All grades Grade 1 Grade 2 Grade 3 Aphthous stomatitis 11 (57.9) 11 (57.9) 0 (0.0) 0 (0.0) Hypercholesterolaemia 11 (57.9) 5 (26.3) 6 (31.6) 0 (0.0) Hypertriglyceridaemia 8 (42.1) 3 (15.8) 3 (15.8) 2 (10.5) Urinary tract infection 8 (42.1) 2 (10.5) 6 (31.6) 0 (0.0) Mucosal inflammation 7 (36.8) 5 (26.3) 1 (5.3) 1 (5.3) Hypertension 6 (31.6) 3 (15.8) 2 (10.5) 1 (5.3) Dermatitis acneiform 5 (26.3) 5 (26.3) 0 (0.0) 0 (0.0) Insomnia 5 (26.3) 5 (26.3) 0 (0.0) 0 (0.0) Catarrh 4 (21.1) 4 (21.1) 0 (0.0) 0 (0.0) Diarrhoea 4 (21.1) 3 (15.8) 1 (5.3) 0 (0.0) Amenorrhoea 3 (15.8) 3 (15.8) 0 (0.0) 0 (0.0) Asthenia 3 (15.8) 3 (15.8) 0 (0.0) 0 (0.0) Headache 3 (15.8) 3 (15.8) 0 (0.0) 0 (0.0) Dysgeusia 3 (15.8) 3 (15.8) 0 (0.0) 0 (0.0) Pharyngitis 3 (15.8) 3 (15.8) 0 (0.0) 0 (0.0) Nasopharyngitis 3 (15.8) 2 (10.5) 1 (5.3) 0 (0.0) Cough 3 (15.8) 3 (15.8) 0 (0.0) 0 (0.0) Menstrual disorder 3 (15.8) 3 (15.8) 0 (0.0) 0 (0.0) Conjunctivitis 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Dermatitis 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Back pain 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Abdominal pain upper 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Epistaxis 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Erythema 2 (10.5) 1 (5.3) 1 (5.3) 0 (0.0) Rash 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Oral herpes 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Dizziness 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Menorrhagia 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Myalgia 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Pyrexia 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Vomiting 2 (10.5) 2 (10.5) 0 (0.0) 0 (0.0) Gamma-glutamyltransferase increased 2 (10.5) 0 (0.0) 2 (10.5) 0 (0.0) Transaminases increased 2 (10.5) 0 (0.0) 1 (5.3) 1 (5.3) All adverse events were coded using the Medical Dictionary for Regulatory Activities (MedDRA) preferred term and graded as per the Common Terminology Criteria for Adverse Events (CTCAE) of the National Cancer Institute (version 4.03) these trials in a considerable percentage of patients over addition, the immunosuppressive properties of everolimus the first year of administration; however, they were mostly may also increase susceptibility to localized or systemic grade 1/2 in severity and few were serious. In addition, infections, which may occur in 65 to 100 % patients adverse events were usually handled with concomitant [13–18]; however, clinical and therapeutic drug moni- medications and/or dose reductions/interruptions, this toring of patients under everolimus treatment may consid- making treatment discontinuation an infrequent need. erably limit its consequences and improve patients’ safety. Inflammation of the mucous membranes of the oral cavity The minimum dose necessary to maintain target everoli- with/without the formation of oral ulcerations are usual mus plasma levels may avoid over treatment and therefore and potentially dose-limiting events during everolimus may limit some adverse events. Previously conducted administration that may appear in 70 to 100 % of patients studies have reported the occurrence of certain adverse receiving this agent for TSC-related tumours [13–18]. In events such as infections not only in patients receiving Robles et al. Orphanet Journal of Rare Diseases (2016) 11:128 Page 7 of 9 consistent with previously established risks and with no new safety concerns [14]. In addition, the incidence of adverse events markedly decreased over time, with the highest incidence over the first year of treatment, then de- clining and reaching rates lower than 10 % in most ad- verse events over the second year and even lower over the third year [14]. The decreasing incidence of adverse events and the fact that most of them could be managed success- fully through dose reductions/interruptions support the importance of careful monitoring and effective manage- ment to optimize patient safety and treatment outcomes. An acceptable safety profile is absolutely needed in this setting, as young adults may be treated lifelong and in- creased cardiovascular risk should be avoided. Continued exposure to everolimus has shown to pro- vide a sustained reduction of TSC-related renal AML lesions over time [14]. These effects may become evident a few months after starting therapy, with a median time to AML response for everolimus of nearly 3 months [13, 14]. The rapid clinical activity of everolimus was especially important in our patient population, which Fig. 2 Reductions from baseline in renal angiomyolipoma volume in showed large AMLs and were therefore at risk of compli- each study visit. The study ended as per protocol 1 year after first patient enrolment, which explains the reduced number of patients cations. Indeed, most patients achieved benefits in terms available at month 12 of reducing renal AML lesions and kidney volumes after a median of 3.3 months of therapy, without exhibiting AML-related complications such as haemorrhages or de- everolimus but also in those receiving placebo [13–16], terioration of renal functioning over the whole study which raises the issue of whether there is a predisposing follow-up. These data are in line with the renal AML effect of the disease that needs to be clarified in future shrinkage shown by previous trials and support the studies. Metabolic events such as hypercholesterolaemia, achievement of greater benefits after longer administra- hypertriglyceridaemia are other potential risks associated tion periods [13, 14], which may even reach up to 86.4 % with everolimus treatment that have been reported in 11 of patients achieving AML reductions ≥30 % over the to 42 % of patients [13, 14, 17, 18], which may require first 3 years of treatment [14]. This AML reduction corrective measurements including dietary adjustments also supports the role of everolimus as a therapeutic and/or cholesterol lowering medication to prevent any alternative to traditional therapies such as selective ar- potential long-term cardiovascular effects. Furthermore, terial embolization, which often lead patients to need amenorrhoea has recently emerged as a potential adverse further embolisations or even nephrectomy in the long- event affecting 13 to 38 % at-risk females during everoli- term [22]. In addition, AML shrinkage over everolimus mus administration [13–16]. Although its relationship to administration appears to occur irrespective of age, gen- everolimus is undergoing investigation, it reinforces the der, and race [13, 16], and levels of plasma angiogenic need for further surveillance in women of childbearing po- markers such as endothelial growth factor D or collagen tential, though pregnancy must be avoided while on treat- type IV seem to be associated with response to everolimus ment. Our female population was two-thirds of the overall [23]. However, further studies are still needed to assess population, most of which were pre-menopausal, and other patient characteristics and/or biomarkers that enable though yet the prevalence of AML in females and males the magnitude of response to be optimized when tailoring in TSC seems to be equal, it should be clarified if females treatment to patients with TSC-related renal AMLs, as well have an increased risk of AML. Furthermore, despite as determining the most appropriate treatment duration to the fact that only one patient reported proteinuria, a maximize and prolong everolimus’ effect over time. more systematic assessment of proteinuria/albumin- The safety and efficacy of everolimus administration for uria should be considered in future studies to confirm TSC-related AML evidenced in our trial is in line with our findings. our previous experience with sirolimus use in this condi- Everolimus administration to patients with TSC- tion. The findings derived from our previous 24-month related AML over the extension phase of the EXIST- phase II-III study carried out in 17 patients with TSC- 2 trial supports a long-term adverse event profile related AML also evidenced an acceptable safety profile of Robles et al. Orphanet Journal of Rare Diseases (2016) 11:128 Page 8 of 9 sirolimus, with stomatitis and hypertriglyceridaemia as the The authors would like to acknowledge all patients who participated in the main adverse reactions [24]. The mTOR inhibition caused study. Medical writing support was provided by Esther Álvarez-García at Dynamic by sirolimus was effective in reducing AML volume, with a S.L., funded by Novartis Farmacéutica S.A., during the preparation of this faster shrinkage at the beginning of treatment that was paper. Responsibility for opinions, conclusions, and interpretation of data lies likely related to its anti-angiogenic effect. These results sup- with the authors. port the role of mTOR inhibitors as promising treatment Funding alternatives for TSC-related AML, with a manageable safety This work was funded by Novartis Farmacéutica S.A., which was involved in profile, adequate efficacy and less aggressiveness than other study design, data analysis and interpretation, and writing of the manuscript. therapeutic options currently available. Availability of data and material The authors acknowledge that the present trial has sev- The dataset supporting the conclusions of this article is included within the eral limitations that should be considered when interpret- article. ing its findings, including the open-label and single-arm Authors’ contributions design. Although the absence of a control group prevented All authors were involved in drafting the manuscript, gave final approval of us from determining the magnitude of the effect, the the version to be published, and agreed to be accountable for all aspects of favourable data available on everolimus risk/benefit bal- the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. NRR made ance would have made the use of placebo unethical and substantial contribution to acquisition, analysis and interpretation of data. RP there was no alternative non-surgical standard therapy for made substantial contribution to acquisition, analysis and interpretation of the disease. Local radiologists were involved in all CT/ data. AGF made substantial contribution to acquisition, analysis and interpretation of data. FV made substantial contribution to acquisition, MRI assessments and no independent central radiologic analysis and interpretation of data. JLAO made substantial contribution to review was conducted, which may have increased inter- acquisition, analysis and interpretation of data. PPS made substantial observer variability. Furthermore, this study could only contribution to acquisition, analysis and interpretation of data. JM made substantial contribution to acquisition, analysis and interpretation of data. BHI address the short-term effect of everolimus administration made substantial contribution to analysis and interpretation of data. JN and the reduced sample size of our study can be regarded made substantial contribution to analysis and interpretation of data. JC made as another limitation. Nonetheless, our findings expand substantial contribution to analysis and interpretation of data. UA made substantial contribution to analysis and interpretation of data. MV made the current information on the use of everolimus for this substantial contribution to conception/design and analysis, and relatively uncommon condition. interpretation of data. CM made substantial contribution to conception/ design and analysis, and interpretation of data. RT made substantial contribution to conception/design and acquisition, analysis, and Conclusion interpretation of data. This trial supports the safety profile and clinical efficacy of Competing interests everolimus for the treatment of TSC-related AML re- This work was funded by Novartis Farmacéutica S.A., which was involved in ported by previous clinical trials. Adverse events exhibited study design, data analysis and interpretation, and writing of the manuscript. over the study were as expected, without raising new The authors of this manuscript declare that JN has received grants from Novartis to participate in clinical trials; AGF, JN, JLAO, RT, FV, BHI, PPS, JC and safety concerns, and were successfully managed with con- NRR have acted as advisors for Novartis in advisory boards; NRR, FV, JLAO, comitant medication, dose reductions, and/or temporary PPS, JM and RT have acted as speakers for Novartis; FV, PPS and RT have treatment interruptions. This manageable safety profile conducted medical writing activities for Novartis; and MV and CM are employees of Novartis Farmacéutica S.A. RP and UA have no conflict of enabled patients to remain under treatment with everoli- interest to disclose. mus, achieving benefits in terms of AML lesions and kidney volumes. Reductions in these AML lesions and Consent for publication Not applicable (the manuscript does not contain any individual persons data). kidney volumes were evident in the majority of patients a few months after starting treatment, more than half Ethics approval and consent to participate achieved radiologic AML response, and none progressed. This trial was conducted in accordance with the World Medical Association These findings expand the information currently available Declaration of Helsinki, all its amendments, and national regulations. It was approved by the ethics committee of Fundació Puigvert (Barcelona, Spain; on the use of everolimus for this condition and warrant reference number: 2012/26) and all patients gave their written informed further assessments to optimize and prolong everolimus’ consent prior to any study procedure. effect in routine clinical practice. Author details 1 Department of Nephrology, Hospital Universitario Infanta Cristina, Abbreviations REDINREN, Avenida de Elvas, S/N, 06006 Badajoz, Spain. 2Department of AML: Angiomyolipoma; CT: Computed tomography; CTCAE: Common Nephrology, Hospital Universitario La Paz, REDINREN, Paseo de la Castellana, terminology criteria for adverse events; IQL: Interquartile range; 261, 28046 Madrid, Spain. 3Department of Urology, Instituto Valenciano de MedDRA: Medical dictionary for regulatory activities; MRI: Magnetic Oncología, Calle del Profesor Beltrán Bàguena, 8, 46009 Valencia, Spain. resonance imaging; mTOR: Mammalian target of rapamycin; SD: Standard 4 Department of Urology, Hospital Universitario 12 de Octubre, Avenida de deviation; TSC: Tuberous sclerosis complex Córdoba, S/N, 28041 Madrid, Spain. 5Department of Urology, Hospital Universitario Puerta del Mar, Avenida Ana Viya, 21, 11009 Cádiz, Spain. 6 Acknowledgements Department of Oncology, Hospital Universitario Clínico San Carlos, Calle del This work was funded by Novartis Farmacéutica S.A., which was involved in Profesor Martín Lagos, S/N, 28040 Madrid, Spain. 7Department of Urology, study design, data analysis and interpretation, and writing the manuscript. Hospital Universitario Vall d’Hebron, Paseo de la Vall d’Hebron, 119-129, Robles et al. Orphanet Journal of Rare Diseases (2016) 11:128 Page 9 of 9 08035 Barcelona, Spain. 8Department of Urology, Hospital Universitario 17. Krueger DA, Care MM, Agricola K, Tudor C, Mays M, Franz DN. Everolimus Virgen de la Victoria, Campus de Teatinos, S/N, 29010 Málaga, Spain. long-term safety and efficacy in subependymal giant cell astrocytoma. 9 Department of Nephrology, Hospital General Universitario de Ciudad Real, Neurology. 2013;80(6):574–80. Calle del Obispo Rafael Torija, S/N, 13005 Ciudad Real, Spain. 10Department 18. Krueger DA, Care MM, Holland K, Agricola K, Tudor C, Mangeshkar P, et al. of Urology, Hospital Universitario Puerta de Hierro Majadahonda, Calle de Everolimus for subependymal giant-cell astrocytomas in tuberous sclerosis. Manuel de Falla, 1, 28222 Majadahonda, Spain. 11Department of Oncology, N Engl J Med. 2010;363(19):1801–11. Hospital Clínico Universitario de Santiago de Compostela, Travesía de 19. Hyman MH, Whittemore VH. National Institutes of Health consensus Choupana, S/N, 15706 Santiago de Compostela, Spain. 12Department of conference: tuberous sclerosis complex. Arch Neurol. 2000;57(5):662–5. Medical Affairs, Novartis Farmacéutica S.A, Gran Via de les Corts Catalanes, 20. Roach ES, Gomez MR, Northrup H. Tuberous sclerosis complex consensus 764, 08013 Barcelona, Spain. 13Inherited Renal Diseases, Department of conference: revised clinical diagnostic criteria. J Child Neurol. 1998;13(12):624–8. Nephrology, Fundació Puigvert, REDINREN, IIB Sant Pau, Universitat 21. National Cancer Institute. Common Terminology Criteria for Adverse Events Autónoma de Barcelona, Cartagena, 340-350, 08025 Barcelona, Spain. (CTCAE), version 4.0. Bethesda, USA. 2010. Available from: http://evs.nci.nih. gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf. Received: 16 June 2016 Accepted: 16 September 2016 Accessed 24 Nov 2015. 22. Eijkemans MJ, van der Wal W, Reijnders LJ, Roes KC, van Waalwijk van Doorn-Khosrovani SB, Pelletier C, et al. Long-term Follow-up Assessing Renal Angiomyolipoma Treatment Patterns, Morbidity, and Mortality: An References Observational Study in Tuberous Sclerosis Complex Patients in the 1. Dabora SL, Jozwiak S, Franz DN, Roberts PS, Nieto A, Chung J, et al. Netherlands. Am J Kidney Dis. 2015;66(4):638–45. Mutational analysis in a cohort of 224 tuberous sclerosis patients indicates 23. Budde K, Zonnenberg BA, Frost M, Cheung W, Urva S, Brechenmacher T, et al. increased severity of TSC2, compared with TSC1, disease in multiple organs. Pharmacokinetics and pharmacodynamics of everolimus in patients with renal Am J Hum Genet. 2001;68(1):64–80. angiomyolipoma and tuberous sclerosis complex or 2. Sancak O, Nellist M, Goedbloed M, Elfferich P, Wouters C, Maat-Kievit A, et lymphangioleiomyomatosis. Br J Clin Pharmacol. 2015; doi: 10.1111/bcp.12834 al. Mutational analysis of the TSC1 and TSC2 genes in a diagnostic setting: 24. Cabrera-Lopez C, Marti T, Catala V, Torres F, Mateu S, Ballarin J, et al. genotype–phenotype correlations and comparison of diagnostic DNA Assessing the effectiveness of rapamycin on angiomyolipoma in tuberous techniques in Tuberous Sclerosis Complex. Eur J Hum Genet. 2005;13(6): sclerosis: a two years trial. Orphanet J Rare Dis. 2012;7:87. 731–41. 3. Kristof AS, Li PZ, Major P, Landry JS. Lymphangioleiomyomatosis and Tuberous Sclerosis Complex in Quebec: Prevalence and Health-care Utilization. Chest. 2015;148(2):444–9. 4. Ahlsen G, Gillberg IC, Lindblom R, Gillberg C. Tuberous sclerosis in Western Sweden. A population study of cases with early childhood onset. Arch Neurol. 1994;51(1):76–81. 5. Kwiatkowski DJ, Manning BD. Tuberous sclerosis: a GAP at the crossroads of multiple signaling pathways. Hum Mol Genet. 2005;14(Spec No. 2):R251–8. 6. Borkowska J, Schwartz RA, Kotulska K, Jozwiak S. Tuberous sclerosis complex: tumors and tumorigenesis. Int J Dermatol. 2011;50(1):13–20. 7. Bissler JJ, Kingswood JC. Renal angiomyolipomata. Kidney Int. 2004; 66(3):924–34. 8. Nelson CP, Sanda MG. Contemporary diagnosis and management of renal angiomyolipoma. J Urol. 2002;168(4 Pt 1):1315–25. 9. Krueger DA, Northrup H, International Tuberous Sclerosis Complex Consensus Group. Tuberous sclerosis complex surveillance and management: recommendations of the 2012 International Tuberous Sclerosis Complex Consensus Conference. Pediatr Neurol. 2013;49(4):255–65. 10. Levy A, Sauvin LA, Massard C, Soria JC. Everolimus (RAD001) and solid tumours: a 2008 summary. Bull Cancer. 2008;95(12):1205–11. 11. Grunwald V, Weikert S, Pavel ME, Horsch D, Luftner D, Janni W, et al. Practical management of everolimus-related toxicities in patients with advanced solid tumors. Onkologie. 2013;36(5):295–302. 12. European Medicines Agency. Afinitor: Summary of Product Characteristics. European Medicines Agency. 2015. Available from: http://www.ema.europa. eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/ 001038/WC500022814.pdf. Accessed 08 Feb 2016. 13. Bissler JJ, Kingswood JC, Radzikowska E, Zonnenberg BA, Frost M, Belousova E, et al. Everolimus for angiomyolipoma associated with tuberous sclerosis complex or sporadic lymphangioleiomyomatosis (EXIST-2): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet. 2013;381(9869):817–24. Submit your next manuscript to BioMed Central 14. Bissler JJ, Kingswood JC, Radzikowska E, Zonnenberg BA, Frost M, Belousova and we will help you at every step: E, et al. Everolimus for renal angiomyolipoma in patients with tuberous sclerosis complex or sporadic lymphangioleiomyomatosis: extension of a • We accept pre-submission inquiries randomized controlled trial. Nephrol Dial Transplant. 2015;31(1):111–9. • Our selector tool helps you to find the most relevant journal 15. Franz DN, Belousova E, Sparagana S, Bebin EM, Frost M, Kuperman R, et al. • We provide round the clock customer support Efficacy and safety of everolimus for subependymal giant cell astrocytomas associated with tuberous sclerosis complex (EXIST-1): a multicentre, • Convenient online submission randomised, placebo-controlled phase 3 trial. Lancet. 2013;381(9861):125–32. • Thorough peer review 16. Kingswood JC, Jozwiak S, Belousova ED, Frost MD, Kuperman RA, Bebin EM, • Inclusion in PubMed and all major indexing services et al. The effect of everolimus on renal angiomyolipoma in patients with tuberous sclerosis complex being treated for subependymal giant cell • Maximum visibility for your research astrocytoma: subgroup results from the randomized, placebo-controlled, Phase 3 trial EXIST-1. Nephrol Dial Transplant. 2014;29(6):1203–10. 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