TABLE OF CONTENTS
Page
SCHEMA........................................................................................................................................ 2
1. OBJECTIVES........................................................................................................................... 6
2. BACKGROUND...................................................................................................................... 7
2.1 Role of Vascular Endothelial Growth Factor (VEGF) in Angiogenesis............................... 7
2.2 Malignant Mesothelioma
2.3 Preclinical Studies with Vascular Endothelial Growth Factor Antisense (VEGF-AS)........ 11
2.4 Animal Clinical Toxicology............................................................................................. 13
2.5 Pharmacokinetic studies 14
2.6 Different VEGF compounds 14
2.7 Phase I/II trial of VEGF-AS in humans with refractory malignancy 16
3. DRUG FORMULATION AND PROCUREMENT............................................................ 20
3.1 VEGF-Antisense Oligonucleotide (VEGF-AS).......................................................... 20
3.1.2 How Supplied......................................................................................................... 20
3.1.3 Reconstitution.......................................................................................................... 20
3.1.4 Route of Administration........................................................................................... 21
3.1.5 Storage................................................................................................................... 21
3.1.6 Stability................................................................................................................... 21
3.1.7 Compatibility........................................................................................................... 21
3.1.8 Availability 21
4. PATIENT SELECTION......................................................................................................... 22
4.1 Eligibility Criteria ...................................................................................................... 22
4.2 Exclusion Criteria........................................................................................................... 23
...............................................................................................................................................
5. TREATMENT PLAN............................................................................................................ 25
5.1 Drug Administration................................................................................................... 25
5.2 Common Toxicity Criteria.............................................................................................. 27
5.3 Supportive Care Guidelines....................................................................................... 27
5.4 Duration of Therapy................................................................................................... 27
6. EXPECTED TOXICITIES/DOSE MODIFICATIONS....................................................... 28
6.1 Expected Toxicities.................................................................................................... 28
6.2 Dosing Delays/Dose Modifications........................................................................... 28
6.3 Definition of Unacceptable toxicity 29
7. CORRELATIVE/SPECIAL STUDIES................................................................................. 29
7.1 Biologic studies of VEGF and VEGFR status 29
8. STUDY CALENDAR............................................................................................................. 31
9. CRITERIA FOR EVALUATION AND ENDPOINT DEFINITIONS............................... 33
9.1 Study Outcome 33
9.2 Definition of Response 33
9.3 Time to Tumor Progression (TTP) 33
9.4 Best Overall Response/Endpoint Definitions 33
9.5 Duration of Response 33
9.6. Overall Survival 34
10. REGULATORY AND REPORTING REQUIREMENTS.................................................. 34
10.1 Adverse Drug Experience Reporting........................................................................ 34
10.1.1 AEs to be reported to VGTI.................................................................................... 34
11. STATISTICAL CONSIDERATIONS.................................................................................. 36
11.1 Summary of Design 36
11.2 Analysis of Results 41
12. RECORDS TO BE KEPT AND DATA SUBMISSION SCHEDULE 46
13. REFERENCES....................................................................................................................... 47
APPENDICES
APPENDIX A, Performance Status Scale
APPENDIX B, IMIG Staging System
APPENDIX C. Blood Processing
APPENDIX D. Data and Safety Monitoring Plan
1.0 OBJECTIVES
Primary objective:
1.1.1 To determine the time to progression of patients with malignant
mesothelioma who are treated with two different doses of VEGF-AS.
Secondary objectives:
1.2.1 To determine the objective response rate of patients with
malignant mesothelioma who are treated with VEGF-AS
1.2.2 To determine the toxicity experienced by patients with malignant
mesothelioma who are treated with VEGF-AS.
1.2.3 To determine median and overall survival of patients with
malignant mesothelioma who are treated with VEGF-AS.
Laboratory objectives:
1.3.1 To measure plasma VEGF levels before, during, and after therapy
as a predictor of outcome.
1.3.2 To collect and store serum samples for possible future
assessment of other antiangiogenic inhibition markers.
2.0 BACKGROUND
2.1 Malignant Mesothelioma
The causative relationship between asbestos and malignant
mesothelioma was first recognized in 1960, when an unusually high incidence of
the disease was observed in South African asbestos miners (Wagner, 1960). About
2500-3000 cases are diagnosed in the United States each year (Kindler, 1999).
Malignant mesothelioma usually arises from the pleura or peritoneum; less
common sites of origin include the pericardium and the tunica vaginalis.
Extensive local progression results in death either from respiratory failure or
from bowel obstruction and inanition. Median survival ranges from 6 to 15
months (Kindler, 1999). Prognostic factors predictive of poor survival include
nonepithelial histology, chest pain, thrombocytosis, leukocytosis, anemia, poor
performance status, advanced age, elevated LDH, symptom onset within 6 months
of diagnosis, weight loss, and male gender (Herndon, 1998; Curran, 1998).
Current therapeutic interventions have not appreciably affected
the natural history of malignant mesothelioma (Alberts, 1988). Surgery is
possible in only a small percentage of patients who present with early stage
disease. Most mesothelioma patients have locally advanced disease, advanced
age, or other comorbid conditions that preclude surgery (Kindler, 1999).
Radiotherapy may be used in selected patients for palliation of
pain, but has no impact on survival (Ball, 1990). Therefore the use of a
systemic anticancer agent is the only treatment option for the majority of
patients with malignant mesothelioma. Unfortunately, reproducible response rates
above 20% are infrequently achieved even with the most active cytotoxic agents,
which include doxorubicin, methotrexate, cisplatin, mitomycin, and
alpha-interferon, and complete responses are rare (Ong, 1996; Ryan, 1998). New
agents with novel mechanisms of action are clearly needed for this disease.
2.2 Role of Vascular Endothelial Growth
Factor (VEGF) in Angiogenesis
Angiogenesis is the process whereby new blood vessels sprout in response to local stimuli. The process of angiogenesis involves the release of angiogenic factors, activation of metalloproteases to break down the extracellular matrix, followed by remodeling. The switch to the angiogenic phenotype is crucial in both tumor progression and metastasis.1 The key factor involved in signaling for angiogenesis in nearly all human tumors is vascular endothelial growth factor (VEGF).2,3 VEGF is a critical growth factor necessary for blood vessel formation. Loss of only one allele in the VEGF gene in knockout mice causes embryonic death.4,5 Likewise, the VEGF receptors are essential for blood vessel formation as shown in gene knockout experiments in mice. 6,7 Heightened expression of VEGF receptors in the endothelial cells of the tumor vasculature further attests to the significance of VEGF in tumor angiogenesis.8,9
VEGF binds to at least three known receptors: flt-1/VEGFR-1, flk-1/KDR/VEGFR-2 and neuropilin-1.10-12 VEGFR-2 is responsible for mitogenic signaling13, while VEGFR-1 participates in cell migration.14-16 VEGF is regulated by several factors including hypoxia, cytokines such as IL-1, activation of certain oncogenes (Ras, Raf, Src), and loss-of-function mutations of p53 and the Von Hippel-Lindau genes.17-22 Elevated tumor or serum VEGF levels has been predictive of poor survival.23-24 The prognostic value of VEGF has been proposed to be related to enhanced angiogenesis in the tumor25-34.
Ectopic expression of VEGFR-2 in non-endothelial cell lines does not lead to a VEGF mediated mitogenic response35, suggesting that only the endothelial cells are configured to carry mitogenic VEGF signal to the nucleus. During neoplastic transformation, non-endothelial cells may acquire aberrant expression of VEGFR-2 and the downstream signaling to VEGF. Autocrine growth factor activity in tumor cells may contribute to metastatic potential and poor outcome.
VEGF is an autocrine growth factor for Kaposi's sarcoma,36 in which tumor cells express an endothelial cell phenotype.37 VEGF inhibitors including VEGF-antisense (VEGF-AS) have been shown to synergize with other agents such as epidermal growth factor antibody against colon carcinoma.38 VEGF-AS has been shown to inhibit VEGF expression as well as blocking the binding of VEGF to VEGFR resulting in growth inhibition of tumor cell lines that express VEGFRs. Furthermore, VEGF-AS has an additive anti-tumor effect when combined with cytotoxic chemotherapeutic agents. In addition to having anti-angiogenic properties, VEGF-AS may also directly inhibit tumor growth in tumors that express the VEGF receptors.
2.3 Role of angiogenesis and
VEGF in mesothelioma
Patients with malignant mesothelioma have higher circulating
levels of VEGF than patients with any other solid tumor (Vermuelen, 1996;
Linder, 1998). In mesothelioma, VEGF expression correlates with microvessel
density (Ohta, 1999). A high intratumoral
microvascular density is associated with a poor survival in
patients with mesothelioma
(Kumar-Singh, 1997; Ohta, 1999).
2.4 Pre-Clinical Studies with Vascular
Endothelial Growth Factor Antisense (VEGF-AS)
VEGF-AS and VEGFR neutralizing antibodies directly inhibit tumor cell
proliferation in vitro:
A wide variety of tumor cell lines express both VEGF and VEGF receptors (VEGFRs). There is a range of response to VEGF inhibition when studied in vitro in our lab. Notably, tumor cell lines that showed the most inhibition of cell viability were those that expressed both VEGF and VEGF receptors. Melanoma and ovarian carcinoma cell lines showed the greatest response, similar to that of KS cell line (KS Y-1). In sharp contrast, cell lines that failed to show response were erythroleukemia (HL-60), T cell leukemia HuT78 and fibroblast (T1) cell lines that lack both VEGF and VEGF receptor expression.
Dose dependent inhibition of cell growth was observed in cell lines that express VEGFRs, the same lines that showed growth inhibition with VEGF-AS. Cell lines that do not express VEGFRs did not show toxicity after VEGF-AS exposure. Blocking VEGFR-1 by itself does not initiate mitogenic signaling; but rather, it potentiates VEGFR-2 signaling by forming heterodimers with it that have a higher VEGF binding affinity. VEGFR-1 antibody does inhibit cell proliferation, although not as strongly as the VEGFR-2 antibody. The differences however, may be related to the activity of the antibody, or less efficient competition of VEGF/receptor interaction. In combination the VEGFR-1 and -2 antibodies were more potent inhibitors of tumor cell proliferation than either alone.
Inhibition of tumor growth in vivo
VEGF-AS (also known as VEGF AS-3) has been tested in murine xenograft models of human ovarian carcinoma and melanoma. Treatment of mice bearing Hey ovarian carcinoma xenografts with 10 mg/kg of VEGF AS-3m resulted in > 90% tumor inhibition. VEGF AS-3m, which is a mixed backbone oligonucleotide containing four ribonucleosides instead of deoxyribonucleosides flanking each end, see figure below, retained anti-tumor activity in the Hey ovarian tumor xenograft model in the absence of either an innate or adaptive immune system. Similarly, VEGF AS-3 (without any mixed backbone) was active against human melanoma M21 xenografts in athymic mice. In addition, an additive effect was observed when VEGF AS-3m was combined with low dose paclitaxel in M21 tumor xenografts, illustrating that the combined treatment regimes were more potent than either agent used alone.
Figure
#1: VEGF-Antisense
VEGF-AS-3 was also active in an orthotopic prostate cancer model. Expression of VEGF increases with advancing prostate carcinoma and even more so when the tumor becomes hormone independent. Palliative therapy is the only treatment for non-resectable tumors. Prostate gland stroma plays a critical role in tissue remodeling and tumor regulation. Direct tumor implantation of the mouse prostate gland with the human prostate tumor cell line (PC3) was performed to determine if inhibition of VEGF would have an anti-tumor effect. Treatment was delayed to ten days post implantation, and the treatment consisted of AS-3m daily at a dose of 10mg/kg. Mice were sacrificed three weeks after tumor implantation and the prostate gland was harvested for analysis. All control mice (n=6) developed tumor at the site of injection in the prostate. Small tumors were seen in only two of six treated mice. This data substantiates the activity of this compound in the orthotopic prostate cancer tumor model.
Growth curves were also examined for apoptotic cells by TUNEL assay in ovarian tumor xenografts. Tumors from control mice showed occasional apoptotic cells not adjacent to the vessel. In contrast apoptosis in the tumors of AS-3m treated mice was more extensive in both perivascular cells and cells distant from vessels were involved. Apoptosis of both tumor cells and endothelial cells is observed, consistent with the proposed dual mode of action of AS-3m in VEGFR-2 positive tumor cells.
Effect of AS-3m on VEGF levels in vivo:
Human (Hey) tumor xenografts were harvested 24 hours after the last dose of therapy and tumor lysates were prepared. VEGF levels were quantitated and adjusted for total protein. Both human (tumor derived) and mouse (host derived) VEGF was inhibited in a dose dependent manner by AS-3m. In a representative experiment approximately 60% reduction in the levels of both human and mouse was observed.
Preclinical development of phosphothiorated AS-3 complimentary to VEGF was undertaken based on the in vitro inhibition of VEGF expression and in vivo inhibition of tumor growth 36,39. Mice studies revealed kidney toxicities at 40 and 50 mg/kg but no toxicity at doses lower than 40 mg/kg. Monkey studies revealed transient elevation of serum Bb complement fragments at doses of 7.5 mg/kg on days 5 and 19, but were comparable to control group values on day 28. The Bb concentration in the 7.5mg/kg/day was comparable both in males and female monkeys on the various days of observations. No other abnormalities were observed either in the complement activation or clotting time.
2.5 Animal Clinical Toxicology
Mouse
Toxicology
The toxicity profile of VEGF-AS was evaluated in the murine model. Mice were given intravenous doses of VEGF-AS on 8 days (on days 0, 1, 2, 3, 4, 7, 8, and 9) and at four dose levels: 10, 20, 30, 40 and 50 mg/kg. Control animals were treated with equal volumes of normal saline.
Administration of intravenous doses of VEGF-AS at doses of 40 mg/kg and 50 mg/kg resulted in the development of lesions in the kidney. Lesions in the kidney were characterized by both hyperplasia and degeneration with apparent recovery by later time points.
Monkey Toxicology
The toxicity profile of VEGF-AS was investigated in cynomolgus monkeys using slow intravenous bolus injection on Wednesday through Sunday of study weeks 1, 3 and 4 (total of 15 injections). The monkeys were assigned to three groups: three male monkeys received doses of 2.5 mg/kg/day; three male and female monkeys received 7.5 mg/kg/day once daily on Days 1-5, 15-19, and 22-26; and three male control monkeys received 0.9% saline on the same schedule as test animals. The monkeys were sacrificed on Day 30, 4 days after the last dose.
Monkeys were observed daily for vital signs, body weight; and blood was obtained for coagulation and complement activation analyses at scheduled intervals. Urine and blood analyses, EKG and ophthalmic examination were performed at baseline and prior to sacrifice. Blood samples for plasma toxicokinetic analysis were collected relative to dosing on Days 1 and 5.
All monkeys survived to scheduled terminal sacrifice. There were no treatment-related findings in the clinical observation, ophthalmic, electrocardiographic, body weight change, or anatomic pathology (macroscopic, microscopic and organ weight) data.
Serum Bb complement fragments were elevated primarily in 7.5 mg/kg/day males at Days 5 and 19, but were comparable to control group values on Day 28. The Bb concentrations in the 7.5 mg/kg/day females were similar to those observed in male monkeys. These transient elevations of serum Bb complement fragments are not apparently adverse to the animals.
No treatment-related differences were noted in the hematology, coagulation, urinalysis, or other clinical chemistry data. No adverse effects were observed for VEGF-AS at a dose level of 7.5 mg/kg/day when administered to cynomolgus monkeys by a slow bolus intravenous injection once daily for 5 days during study weeks 1, 3 and 4.
2.6 Pharmacokinetics
The pharmacokinetics and tissue distribution of VEGF-AS in Balb/c nu/nu mice was determined after a single IV dose of 30 mg/kg. Following IV administration of VEGF-AS the peak plasma concentration at 5 minutes was 34.26 ± 12.89 mg/ml. Intact AS-ODN could be detected up to 24 h. At 48 h, VEGF-AS was not detectable. The decrease in plasma concentration of AS-ODN followed a biexponential pattern with an initial half-life (t1/2a) of 0.33 ± 0.031 h and a terminal half-life (t1/2b) of 8.23 ± 2.31 h. The area under the plasma concentration-time curve was 16.95 ± 4.53 mg.h/ml, with a total body clearance of 1875.23 ± 589.84 mL/h/kg and volume of distribution of 21.47 ± 4.80 L/kg.
Following IV administration of VEGF-AS in cynomolgus monkeys, the peak plasma concentration at 5 minutes was 22.60 ± 3.51 mg/ml at 2.5 mg/kg dose and 67.50 ± 17.50 mg/ml at 7.5 mg/kg respectively. Intact VEGF-AS could be detected up to 4 h. At 24 h, VEGF-AS was not detectable. The terminal half-lives (t1/2) were 0.55 ± 0.05 h and 0.68 ± 0.11 h at low and high dose respectively. The area under the plasma concentration-time curve increased from 11.36 ± 2.39 mg.h/ml at 2.5 mg/kg dose to 51.84 ± 14.53 mg.h/ml at 7.5 mg/kg dose. The total body clearance was 227 ± 51.51 mL/h/kg at 2.5 mg/kg, while it was 152.31 ± 33.27 mL/h/kg at 7.5 mg/kg dose. The volume of distribution was 0.18 ± 0.04 L/kg at low dose, and 0.15 ± 0.03 L/kg at high dose respectively.
2.7 Comparison with other VEGF compounds
Several other VEGF inhibitors are currently in clinical development that target only VEGF. VEGF-AS however targets other VEGF family members to include VEGF, VEGF-C and VEGF-D. In addition, VEGF inhibitors in clinical development, such as SU5416 have had issues related to solubility, with diluents such as cremaphor which cause phlebitis and liver toxicity. The anti-VEGF antibody, bevacizumab, has been associated with thromboembolic complications, renal bleed, hypertension, stroke, and myocardial infarction.
In pre-clinical study, VEGF AS3 has shown remarkable safety profile in primates. Murine toxicity studies showed renal lesion only at very high dose levels that are not expected to be achieved in human trials. We, however, remain vigilant of any and all toxicities and acknowledge that safety comes first.
A comparison of the corresponding areas of the VEGF family members is shown below: the highlighted bases indicate identity between either VEGF-B, -C, -D or PlGF and VEGF. Homology between the genes is not high in this region. Comparison of the sequences in the human and mouse VEGF genes that are complementary to AS-3. Mouse sequence shown here is nucleotides 288-308 of the sequence reported by Claffey and coworkers.40 Identity is indicated by highlighted blocks.
Figure
#2: Base identity between VEGF –A,
-B,-C,-D and PlGF
Figure
#3: Receptor usage of VEGF family
members
Figure #4: VEGF-AS targets
VEGF-A, VEGF-C and VEGF-D
Western blot
2.8 Phase I study of VEGF-AS in humans with refractory malignancy
1. Study objectives: (a) To determine the dose limiting toxicity
(DLT) and maximum tolerated dose (MTD)of VEGF-AS given as an IV infusion daily X 5 days (initial regimen), or, given daily x 5 days every other week for 4 months (amended regimen), in patients with relapsed or refractory malignancy, with stable disease or better after initial 28 day study period; (b) To evaluate the pharmacokinetic profile of VEGF-AS; (c) Secondarily, to preliminarily identify any evidence of objective tumor response in patients treated with IV VEGF-AS; (d) To determine VEGF A levels in plasma, pre and post infusions, and to compare therapeutic results with VEGF-A levels.
2. Study design: Phase I, dose escalation study, accruing 3 patients to each level. In the absence of DLT at a given level, escalation to the next level occurred. If DLT occurred at any given level, a total of 6 patients were to be added to that dose level. No dose escalations were permitted within patients. The MTD was to be the dose level where 0 or 1 DLTs were observed.
3. Definition of dose limiting toxicity (DLT): Any grade 3
coagulopathy; any grade 2 thrombotic event; grade 2 neuropathy; any grade 3 or 4 non-hematologic toxicity; grade 3 or 4 drug related thrombocytopenia; grade 4 drug related other hematologic toxicity.
4. Treatment dose levels employed:
|
LEVEL 1 |
15 mg/m2 |
|
LEVEL 2 |
22.5 mg/m2 |
|
LEVEL 3 |
30 mg/m2 |
|
LEVEL 4 |
37.5 mg/m2 |
|
LEVEL 5* |
47 mg/m2 |
|
LEVEL 6* |
59 mg/m2 |
|
LEVEL 7* |
74 mg/m2 |
|
LEVEL 8* |
85 mg/m2 |
|
NEXT LEVELS* |
Increase in 11 mg/m2 increments |
*The study design changed at Level 5, to allow additional protocol treatment in patients with stable disease or better after the first 5 day infusion. In these subjects, additional VEGF-AS was given as an IV infusion, daily x 5 days, every other week for a total of 8 cycles (4 months).
5. Entry criteria: (a) Any malignancy for which standard therapeutic
measures are no longer effective; (b) All stages with measurable or evaluable disease; (c) Age 18 years or older; (d) KPS of 50% or better, and estimated survival of at least 3 months; (e) Bilirubin Ł 1.5 upper limit of normal (ULN); AST/ALT Ł 2.5 ULN; (f) Absolute neutrophil count ł 1500/mm3; platelets ł75,000/mm3 (unless due to marrow involvement); (g) Creatinine Ł1.5 mg/dl; (h) Signed informed consent
6. Exclusion criteria: (a) involvement of brain or CSF; (b) History of
deep vein thrombosis or pulmonary embolism or stroke; (c) History of CHF, unstable angina, cardiac arrhythmia, or MI; (d) Chemotherapy or XRT within 4 weeks; (e) Major surgery within 2 weeks; (f) Pregnant or lactating females.
7. Patient characteristics: 26 patients have been entered, will full follow-up now available. The median age is 57 years (range 19-83). Males=19; females-7. Prior therapy included systemic chemotherapy in 24 (92%); biologics/immunotherapy in 13 (50%); radiation in 9 (35%) and stem cell transplant in 1 (4%). Tumor types accrued included lymphoma in 5 (21%); sarcoma in 4 (13%); AIDS-related Kaposi’s sarcoma in 3 (13%); renal cell carcinoma in 3 (13%); colon cancer in 2 (8%); lung cancer in 2 (8%), and miscellaneous cancers in 7 (25%), including multiple myeloma, pancreas, melanoma, myoepithelioma, prostate cancer, thyroid and adenoid cystic carcinoma in one patient each.
8. Toxicity
CTC GRADE
|
TYPE |
GRADE 1 |
GRADE 2 |
GRADE 3 |
GRADE 4 |
% Toxicity |
|
Neutropenia |
-- |
-- |
0 |
0 |
0 |
|
Anemia |
-- |
0 |
1 |
0 |
4 |
|
Low platelet |
-- |
0 |
0 |
0 |
0 |
|
Fatigue |
5 |
0 |
0 |
0 |
19% |
|
Constipation |
4 |
0 |
0 |
0 |
15% |
|
Hypotension |
3 |
0 |
0 |
0 |
12% |
|
Diarrhea |
1 |
2 |
0 |
0 |
12% |
|
Perioral numbness |
2 |
0 |
0 |
0 |
8% |
|
Insomnia |
2 |
0 |
0 |
0 |
8% |
Four serious adverse events have been reported. These include 3 patients who have died due to progressive malignant disease. Additionally, one patient with lymphoma, with pre-existing neutropenia due to extensive marrow involvement, developed neutropenic fever.
Through dose level 9 (96 mg/m2), there has been no dose limiting toxicity; no significant hematologic toxicity, except one case of grade 3 anemia in a patient who was transfusion dependent prior to study initiation; no evidence of coagulopathy or thrombotic event; no significant alteration in complement profiles; no significant cardiac toxicity.
9. Plasma VEGF levels on study: Plasma VEGF levels were
measured by ELISA at baseline, 24 hours after completion of VEGF-AS infusion; 5 days after completion of infusion; and weekly in patients on the revised schedule. VEGF levels are available on 25 patients. The median baseline VEGF level was 140 pg/ml (range 16-686 pg/ml). The VEGF levels declined by 25% or more at 24 hours in 14/25 (56%); were unchanged in 6/25 (24%); and increased by more than 25% in 5/15 (20%).
10. Preliminary data on clinical response
In an ongoing Phase I trial of VEGF-AS in patients with relapsed or refractory malignancies, one objective complete remission has been observed in a patient with AIDS-related Kaposi’s sarcoma lasting for 4 months. One patient with cutaneous T-cell had a mixed response and several patients with various solid tumors to include malignant mesothelioma have had stable disease.
3. DRUG FORMULATION AND
PROCUREMENT
3.1.1 VEGF-Antisense Oligonucleotide (VEGF-AS)
VEGF-AS is manufactured by Avecia, Milford, MA for VasGene Therapeutics. The clinical vials are formulated by PrimaPharm, Inc., San Diego, CA. Each lyophilized vial contains 55 mf of VEGF-AS.
3.1.2 How Supplied
VEGF-AS is supplied by VasGene Therapeutics Inc. as a lyophilized powder with vial containing 55 mg of VEGF-AS for injection
3.1.3 Reconstitution
To reconstitute, first add 5.5 mL 0.9% Sodium Chloride, USP for injection to the vial containing the VEGF-AS. Swirl gently to dissolve. The resulting concentration of VEGF-AS is 10 mg/ml. Withdraw the required amount of the VEGF-AS solution as needed through a syringe and mix it in the bag containing saline.
3.1.4
Route
of administration
Intravenous infusion over at least 60 minutes
3.1.5
Storage
The
intact vials should be stored frozen (-200C).
3.1.6
Stability
The antisense oligonucleotides are
demonstrated to be quite stable as lyophilized products at –200C.
This has been observed with antisense for c-Raf and for Bcl/2. However, we are conducting a thorough
stability program with the lyophilized preparation of VEGF-AS under the
guidelines of ICH. We believe that there are no issues with the stability of
the product after reconstitution.
CAUTION: The single-use lyophilized dosage form contains no antibacterial preservatives. Therefore, it is advised that the reconstituted product be discarded 8 hours after initial entry.
Stability of VEGF-AS Solution at 37oC for 7 days shown below b[pk3]y polyacrylamide gel electrophoresis
3.1.7 Compatibility
VEGF-AS is compatible with 0.9% sodium chloride injection, USP.
3.1.8 Availability
Drug Ordering: To obtain a supply of VEGF-AS, the investigational pharmacist should call Dr. Parkash Gill[pk4] at 323-865-3909 during normal business hours (9:00 am to 5:00PM, Pacific Standard Time). The agent will be shipped via express courier to arrive on a weekday.
Drug Accountability:
The Investigator, or a responsible party designated by the investigator, must maintain a careful record of the inventory and disposition of all drugs received from VasGene Therapeutics.
4. PATIENT SELECTION
4.1 Eligibility Criteria
4.1.1 Patients
must have histologically or cytologically confirmed malignant pleural or
peritoneal mesothelioma, epithelial, sarcomatoid, or mixed subtype.
4.1.2 Patients must have
had undergone prior systemic treatment, radiotherapy, or surgical procedure of
curative intent for malignant pleural or peritoneal mesothelioma. Prior
intrapleural cytotoxic agents (including bleomycin) will be included as prior
therapy.
4.1.3 Patients must have
measurable disease, defined as at least one lesion that can be accurately
measured in at least one dimension (longest diameter to be recorded) as >20
mm with conventional techniques or as >10 mm with spiral CT scan. Pleural
effusions and ascites are not considered measurable lesions.
4.1.4 Patients with
pleural mesothelioma must be IMIG stage >II (see appendix B for the IMIG
staging system).
4.1.5 Age > 18 years.
4.1.6 ECOG performance status < 2 (Karnofsky > 50%, see Appendix A) and an estimated survival of at least 3 months
4.1.7 Patients must have adequate organ and marrow function as defined
below:
Absolute neutrophil count >1,000/ml
Platelets >50,000/ml
Total bilirubin < 2.0x the upper limits of institutional normal
AST/ALT < 2.5x the upper limits of institutional normal
Serum creatinine < 2.0 mg/dl
4.1.8 The effects of VEGF-AS on the developing human fetus are unknown. For this reason, women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately.
4.1.9 Ability to understand and the willingness to sign a written informed consent document.
4.1.10 Patients with history of prior malignancy may be accrued provided that other eligibility criteria are met.
4.1.11 Must have medical records available to document start date of most recent prior therapy and time to progression for most recent prior therapy.
4.2 Exclusion Criteria
4.2.1 Patients who have had chemotherapy, immunotherapy or radiotherapy within 4 weeks prior to entering the study and 6 weeks from nitroso-urea-containing chemotherapy. All patients should have recovered from all toxicities of prior therapy.
4.2.2 Patients receiving therapy with other investigational agents at the time of study enrollment.
4.2.3 Patients with cancer involving the brain, or brain metastases.
4.2.4 Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
4.2.5 Pregnant and nursing women are excluded from this study as VEGF-AS may be harmful to the developing fetus or nursing infant.
4.2.6 Patients who had any major surgery within 4 weeks
5.0 TREATMENT PLAN
5.1 Drug administration
Patients will receive VEGF-AS as an intravenous (IV) infusion over a minimum of 60 minutes given three days weekly (Monday, Wednesday, Friday, (d1, d3 d5) for a total of 8 weeks. In subjects with stable or improved disease at 8 weeks, additional VEGF-AS will be given twice weekly for a total of 24 weeks, or until tumor progression, or toxicity.
Patients will be
randomized to the following treatment doses of VEGF-AS as follows:
VEGF-AS VEGF-AS
100
mg/m2 200 mg/m2
TIW
weeks 1-8 TIW,
weeks 1-8
Re-evaluate
for response
Patients with Stable or better disease after 8 weeks can continue to receive BIW therapy (Monday, Thursday or Tuesday Friday) at their respective dose level until disease progression or unacceptable toxicity.
In the event of a holiday, treatment can be omitted or given one day later. Patients will be permitted to miss up to 2 weeks of therapy for reasons unrelated to toxicity. Patients who have treatment delays of greater than 2 weeks not due to toxicity will be removed from therapy.
There will be no increase in dose among
individual subjects
5.2
Toxicity Criteria
Life-threatening
reactions which may be due to drug administration and all fatal reactions
occurring on this study (during or within 30 days of treatment) will be
reported immediately by phone. A written report will be submitted within ten
(10) working days. The first occurrence
of any previously unknown clinical event, regardless of grade, will be reported
by phone within 24 hours to the IRB and to the Clinical Director at VasGene
Therapeutics Inc (VGTI). A written
report is required.
5.3 Supportive Care Guidelines
Colony stimulating factors (CSFs) should not be used as prophylaxis during the first 5 days of therapy but can be given at the discretion of the investigator, if the subject develops febrile neutropenia.
Other appropriate supportive care medications may be administered at the investigator's discretion.
5.4 Duration of Therapy
Patients will initially be treated on a three times weekly schedule for 8 weeks, unless treatment is stopped earlier due to one of the reasons outlined below. In patients with stable or better disease after 8 weeks, they will be allowed to receive an additional twice weekly therapy until tumor progression or toxicity. Reasons for early termination of study include:
§ Disease progression
§ Intercurrent illness that prevents further administration of treatment
§ Unacceptable toxicity
§ Patient decides to withdraw from the study
§ General or specific changes in the patient's condition that render the patient unacceptable for further treatment in the judgment of the investigator.
6. EXPECTED TOXICITIES/DOSE MODIFICATIONS
6.1
Expected Toxicities
The study will utilize the NCI Common Terminology Criteria for Adverse Events (CTCAE) version 3.0, for toxicity and Adverse Event Reporting. Additionally, a copy of the CTCAE version3.0 can also be downloaded from the CTEP home page (http://ctep.info.nih.gov/). All appropriate treatment areas should have access to a copy of the CTC version 3.0.
Side effects seen in animals that
were given doses far exceeding that planned for this study include lesions in
the kidney and heart and changes in immune function.
VEGF-AS has also been studied in 30 humans to date. Most side effects have been minor (grade 1 or 2). The most common side effects seen in these patients (all less than 20%) were as follows: fatigue, constipation, low blood pressure, diarrhea, numbness around the lips, and difficulty sleeping. One patient had a grade 3 decrease in red blood cells; this individual was red cell transfusion dependent at study entry. No other grade 3 toxicity has been seen
Proteins similar to VEGF-AS have been given to humans and are associated with the following side effects: fatigue, fevers, chills, hot flashes or a flushing sensation, back pain, muscle aches, tender or swollen lymph nodes, lowering of blood counts, abnormal liver and kidney tests, abnormal blood clotting tests, upset stomach, nausea, vomiting, decrease appetite, skin rash, high or low blood pressure, and fluid retention. Another side effect could be an increased risk of developing blood clots and/or an increased risk of bleeding or bruising. It is possible that an allergic reaction could develop resulting in symptoms such as rapid heart beat, flushing, difficulty breathing. If not treated effectively, a severe allergic reaction could result in death.
6.2 Dosing
Instructions and Modifications
6.2.1 For patients that weigh > 130% of ideal body weight, use the following formula 0.5x (ABW + 1.3xIBW). To calculate ideal body weight (IBW) in adults:
Males = 50 kg + [(2.3)(HT-60)] kg
Females = 45.5 kg + [(2.3)(HT-60)] kg
where HT is a patient’s height in inches
6.2.2 Dose Modifications:
Hematologic Toxicity
All treatment should be held permanently for patients experiencing drug related grade 3 thrombocytopenia, or grade 3 febrile neutropenia, or grade 4 neutropenia, unless these cytopenias are consistent with the patients’ baseline status, and secondary to marrow infiltration by malignant disease. There will be no dose modification of anemia.
All other non-hematologic toxicities:
For > Grade 3 or greater drug related toxicity, all therapy will be held permanently.
Doses that are missed on any day of any cycle due to toxicity will not be administered at a later day. Doses that are missed for reasons other than toxicity may be administered at a later day at the discretion of the principal investigator.
6.3 Definition of Unacceptable
Toxicity
Unacceptable toxicity for dose limiting toxicity (DLT) will be defined as:
6.3.1 Hematology: Grade 4 thrombocytopenia or febrile neutropenia that is not definitely attributed to marrow infiltration by malignant disease