Riccardo Cecchin

Background: Substantial inter-individual variability in imatinib systemic exposure may influence both efficacy and toxicity. Based on recommendations of the International Association for Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT), the IRCCS-CRO of Aviano started in 2018 offering physicians the opportunity to monitor plasma concentrations of imatinib and its active metabolite, norimatinib, as part of a diagnostic service for patients with Gastrointestinal Stromal Tumor (GIST). This study aims to evaluate the potential clinical utility of imatinib Therapeutic Drug Monitoring (TDM) in predicting response and toxicity in a real-world cohort of 63 patients with GIST. Methods: Imatinib and its active metabolite norimatinib trough concentrations (C_min) were quantified using a validated LC–MS/MS method. Associations between drug exposure and clinical–demographic characteristics, treatment-related toxicity, and progression-free survival (PFS) were evaluated. Results: A total of 437 plasma samples from 63 patients were collected. Marked inter- and intra-patient variability in imatinib exposure was observed (43% and 31% respectively); 67% of patients receiving 400 mg/day had a C_min below the recommended target concentration (1100 ng/mL). Female sex was significantly associated with higher imatinib exposure (median C_min 1114 vs. 786 ng/mL in males; p = 0.0018). Combined age–sex analysis showed a significant difference between women and men < 60 years (1041 vs. 668 ng/mL; p = 0.0068, Bonferroni-adjusted). A strong exposure–toxicity relationship emerged, with higher imatinib levels in samples collected at toxicity occurrence vs. the others (1728 vs. 927 ng/mL; p < 0.0001), without a direct association between sex and toxicity. No significant association between C_min and PFS was observed; however, disease progression was more frequent in patients with C_min < 500 ng/mL and absent in those with C_min >1500 ng/mL (60% vs. 0%, respectively). Conclusions: TDM was found to be a potentially useful tool for predicting clinically relevant toxicity and outcome. Sex and age significantly influence exposure, supporting tailored dosing strategies.

Accurate measurement of androgen receptor pathway inhibitors (ARPIs) and their active metabolites is essential for pharmacokinetic studies and therapeutic drug monitoring (TDM) in patients with prostate cancer (PC). However, their simultaneous determination in human plasma is analytically challenging because of the wide concentration ranges. This study aimed to develop and validate a sensitive and robust LC–MS/MS method for the quantification of abiraterone, Δ4-abiraterone, enzalutamide, N-desmethyl enzalutamide, darolutamide, keto-darolutamide, apalutamide, and N-desmethyl apalutamide in human plasma. Sample preparation was performed by protein precipitation, followed by chromatographic separation and detection using multiple reaction monitoring with isotopically labeled internal standards (total run time 6.5 min). The method was validated in accordance with regulatory guidelines by assessing selectivity, linearity, sensitivity, accuracy, precision, recovery, matrix effects, and stability. The assay demonstrated good linearity (≥0.997) across clinically relevant concentration ranges, with lower limits of quantification between 0.1 and 40 ng/mL, depending on the analyte. Intra- and inter-day precision and accuracy were within acceptable limits, and recovery and matrix effects were consistent across different plasma matrices. Stability experiments conducted in plasma and whole blood provided practical guidance for sample handling. The method was successfully applied to 79 plasma samples from 61 patients with metastatic PC. Measured concentrations were generally consistent with published pharmacokinetic data, while unexpectedly high ABI levels were observed. Sample collection occurred between 1 and 28 h after the last drug intake, enabling assessment of the analytical method across the entire pharmacokinetic profile.