Dual-Pathway Inhibition: A New Frontier in Leiomyosarcoma Management
Highlight
- The combination of cabozantinib and temozolomide achieved a 12-week progression-free survival (PFS) rate of 74% in patients with advanced leiomyosarcoma.
- Dual targeting of the VEGF and MET pathways alongside alkylating chemotherapy represents a novel mechanistic approach for soft tissue sarcomas.
- The treatment regimen demonstrated a manageable safety profile, with hematologic toxicities being the most frequent high-grade adverse events.
The Challenge of Advanced Soft Tissue Sarcomas
The clinical management of unresectable or metastatic soft tissue sarcomas (STS) remains one of the most formidable challenges in adult oncology. Among the various subtypes, leiomyosarcoma (LMS)—a malignancy of smooth muscle origin—is particularly aggressive, often characterized by a high propensity for hematogenous metastasis and resistance to conventional cytotoxic regimens. While frontline doxorubicin-based therapies remain the standard of care, subsequent lines of treatment, including gemcitabine, docetaxel, and pazopanib, offer limited long-term disease control. The median overall survival for patients with metastatic disease remains distressingly low, underscoring an urgent unmet medical need for innovative, evidence-based therapeutic strategies.Recent research has pivoted toward the tumor microenvironment and the molecular drivers of sarcoma progression. Evidence suggests that leiomyosarcomas often overexpress the MET proto-oncogene and are highly dependent on vascular endothelial growth factor (VEGF) for angiogenesis. Cabozantinib, a potent multikinase inhibitor targeting MET, VEGFR2, and AXL, has shown promise in various solid tumors. When combined with temozolomide, an oral alkylating agent capable of inducing DNA damage, there is a strong biological rationale for synergistic antitumor activity. This combination aims to simultaneously disrupt the vascular supply, inhibit growth-promoting pathways, and directly compromise the genomic integrity of the malignant cells.
Study Design: The Cabozantinib and Temozolomide Combination
The study, published in The Lancet Oncology, was a multicenter, single-arm, lead-in phase 2 trial conducted across five academic Sarcoma Centers of Excellence in the United States. The trial enrolled 72 patients, stratified into two cohorts: Cohort 1 focused on unresectable or metastatic uterine and non-uterine leiomyosarcoma (n=42), while Cohort 2 served as an exploratory group for other soft tissue sarcomas (n=30).Eligible participants were required to be 18 years or older with an ECOG performance status of 0-1, adequate organ function, and measurable disease according to RECIST 1.1. Patients were permitted to have received up to five prior chemotherapy regimens, highlighting the heavily pretreated nature of the study population.The intervention involved oral cabozantinib at a starting dose of 40 mg daily and temozolomide at 150 mg/m2 on days 1–5 of a 28-day cycle. Starting from the second cycle, the temozolomide dose was escalated to 200 mg/m2 if hematologic parameters (ANC >1.5 × 10^9/L and platelets >100 × 10^9/L) were maintained. The primary endpoint for the leiomyosarcoma cohort was the progression-free survival (PFS) rate at 12 weeks.
Clinical Outcomes: Meaningful Progression-Free Survival
In the leiomyosarcoma cohort (Cohort 1), the combination therapy yielded significant clinical benefit. At the primary endpoint of 12 weeks, 74% (31 of 42) of patients were still receiving treatment without disease progression. When utilizing the Kaplan-Meier estimate to account for censoring and patients who may have discontinued treatment for reasons other than progression, the 12-week PFS rate reached 79.4% (95% CI 68.6–86.8). These figures are particularly noteworthy given the refractory nature of the disease in many of the enrolled participants.For Cohort 2, which included diverse STS subtypes, the trial provided exploratory data on the efficacy of this dual-drug regimen across a broader spectrum of sarcomas. While LMS patients showed the most robust response, the findings suggest that the cabozantinib-temozolomide backbone may have utility beyond smooth muscle malignancies, though further subtype-specific investigation is required. At the time of the study’s conclusion, 48% of patients in the LMS cohort and 77% in the exploratory STS cohort had died due to disease progression, reflecting the high-risk nature of the advanced metastatic setting.
Safety and Tolerability Profile
The safety analysis included all 72 enrolled patients. Consistent with the known profiles of both agents, treatment-related adverse events (AEs) were nearly universal (99%), though most were low-grade. The most common grade 3 or 4 adverse events were predominantly hematologic: platelet count decrease (30%) and neutrophil count decrease (18%). Non-hematologic grade 3-4 events included hypertension (10%) and diarrhea (8%).Crucially, the study reported no treatment-related deaths. The toxicity profile appeared manageable through standard dose modifications and supportive care, indicating that the combination of a multikinase inhibitor and an alkylating agent does not result in cumulative or unexpected toxicity that would preclude its use in a clinical setting.
Expert Perspective: Mechanistic Synergy and Clinical Implications
From a clinical standpoint, the success of the cabozantinib and temozolomide combination in leiomyosarcoma is biologically plausible. The MET pathway is known to contribute to both primary and acquired resistance to anti-VEGF therapies; by inhibiting both MET and VEGFR2, cabozantinib may provide a more comprehensive blockade of tumor angiogenesis and survival signals than earlier-generation inhibitors. Furthermore, temozolomide’s efficacy in certain sarcoma subtypes has been documented, and its oral administration makes it an attractive partner for cabozantinib in creating an all-oral outpatient regimen.However, as a single-arm phase 2 trial, certain limitations must be acknowledged. The lack of a randomized control group makes it difficult to definitively isolate the contribution of each drug or to compare the regimen directly to current second-line standards. Nevertheless, the high rate of 12-week PFS provides a strong signal of activity that warrants follow-up in a randomized phase 3 setting. Clinicians should also remain vigilant regarding the hematologic toxicity, particularly thrombocytopenia, which was the most frequent high-grade adverse event.
Conclusion
The combination of cabozantinib and temozolomide represents a meaningful advancement in the search for effective therapies for advanced leiomyosarcoma. With a 12-week PFS rate of 74% and a safety profile that aligns with current oncology standards, this regimen offers a viable potential treatment option for a patient population with historically limited choices. Future research should focus on identifying molecular biomarkers that might predict which patients within the heterogeneous STS population are most likely to benefit from this dual-pathway approach.
Funding and Trial Registration
This study was funded by Exelixis. ClinicalTrials.gov Identifier: NCT04200443.
References
Monga V, Okuno S, Van Tine B, et al. Cabozantinib and temozolomide in patients with unresectable or metastatic leiomyosarcoma and other soft tissue sarcomas: a multicentre, single-arm, lead-in phase 2 trial. Lancet Oncol. 2026 Feb;27(2):223-232. doi: 10.1016/S1470-2045(25)00654-0.
