@article{4bbb516e2d3c4abc807ee2b6a45ae367,
title = "Phase 1 study of EGFR-antisense DNA, cetuximab, and radiotherapy in head and neck cancer with preclinical correlatives",
abstract = "BACKGROUND: Cetuximab combined with radiation therapy (RT) is an evidence-based treatment for locally advanced head and neck squamous cell carcinoma (HNSCC); however, locoregional failure remains the primary cause of cancer-related death in this disease. Intratumoral injection of epidermal growth factor receptor (EGFR)-antisense plasmid DNA (EGFR-AS) is safe and has been associated with promising lesional responses in patients who have recurrent/metastatic HNSCC. For the current study, the authors investigated the antitumor effects of cetuximab and EGFR-AS in preclinical HNSCC models and reported their phase 1 experience adding intratumoral EGFR-AS to cetuximab RT. METHODS: Antitumor mechanisms were investigated in cell line and xenograft models. Phase 1 trial eligibility required stage IVA through IVC HNSCC and a measurable lesion accessible for repeat injections. Patients received standard cetuximab was for 9 weeks. EGFR-AS was injected weekly until they achieved a lesional complete response. RT was delivered by conventional fractionation for 7 weeks, starting at week 3. Research biopsies were obtained at baseline and week 2. RESULTS: When added to cetuximab, EGFR-AS decreased cell viability and xenograft growth compared with EGFR-sense control, partially mediated by reduced EGFR expression. Six patients were enrolled in the phase 1 cohort. No grade 2 or greater EGFR-AS–related adverse events occurred. The best lesional response was a complete response (4 patients), and 1 patient each had a partial response and disease progression. EGFR expression decreased in 4 patients who had available paired specimens. CONCLUSIONS: In preclinical models, dual EGFR inhibition with cetuximab and EGFR-AS enhanced antitumor effects. In a phase 1 cohort, intratumoral EGFR-AS injections, cetuximab, and RT were well tolerated. A phase 2 trial is needed to conduct an extended evaluation of safety and to establish efficacy.",
keywords = "antisense, cetuximab, epidermal growth factor receptor (EGFR), head and neck cancer, oligonucleotide, phase 2",
author = "Bauman, {Julie E.} and Umamaheswar Duvvuri and Sufi Thomas and Gooding, {William E.} and Clump, {David A.} and Brian Karlovits and Ahmad Wehbe and Miller, {Frank R.} and Seungwon Kim and Malabika Sen and Heron, {Dwight E.} and Grandis, {Jennifer R.} and Athanassios Argiris",
note = "Funding Information: This work was supported by grants from the National Cancer Institute (1R21CA130241 to Athanassios Argiris; P50CA097190 to Jennifer R. Grandis; and in part by P30CA047904 to the University of Pennsylvania Cancer Institute Biostatistics Core Facility) and by the American Cancer Society (CRP-08-229-01 to Jennifer R. Grandis). Manufacture of EGFR-AS was supported by the National Institute of Health{\textquoteright}s National Gene Vector Laboratory Program. Funding Information: This work was supported by grants from the National Cancer Institute (1R21CA130241 to Athanassios Argiris; P50CA097190 to Jennifer R. Grandis; and in part by P30CA047904 to the University of Pennsylvania Cancer Institute Biostatistics Core Facility) and by the American Cancer Society (CRP-08-229-01 to Jennifer R. Grandis). Manufacture of EGFR-AS was supported by the National Institute of Health?s National Gene Vector Laboratory Program. This phase 1 trial was designed to enroll 11 patients to a fixed-dose combination of intratumoral EGFR-AS, cetuximab, and RT. Because no grade 2 or higher adverse event (AE) was observed during phase 1 development of intratumoral EGFR-AS, the highest previously tested dose of EGFR-AS was implemented without a plan for further escalation. The primary objective was to evaluate safety. The primary endpoint was DLT, defined as any grade 3 or 4 AE according to the National Cancer Institute Common Toxicity Criteria for Adverse Events, version 4.0 at least possibly related to EGFR-AS. The design sought to rule out an unacceptable DLT rate ?20%. If no grade 3 or 4 AEs caused by EGFR-AS were observed, then the upper 90% confidence bound for the DLT rate would be <20%. Locoregional RECIST responses were categorized by computed tomography scans obtained 8 to 12 weeks after the completion of RT. To qualify for a lesional CR, complete disappearance of the injected lesion was required. To qualify for a locoregional CR, complete disappearance of all locoregional disease within the radiated head and neck field was required. In patients with stage IVC disease, distant metastases were not included as target lesions when assessing lesional and locoregional response. HNSCC cell lines and reagents, viability and immunoblotting assays, xenograft models, and statistical methods are described in Supporting Figure. The phase 1 trial was approved by the Institutional Review Boards of the University of Pittsburgh and the University of Texas San Antonio; both sites were nationally registered at clinicaltrials.gov (NCT00903461 and NCT01592721). All patients provided written, informed consent. Key eligibility criteria included: stage IVA through IVC, histologically confirmed HNSCC of the oral cavity, oropharynx, hypopharynx, or larynx, as defined by the American Joint Committee on Cancer Staging Handbook, seventh edition; the presence of a primary tumor or lymph node that was measurable according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 and accessible for repeated injections and mandatory research biopsies; and an Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2. Radiation-naive patients who had stage IVC disease with asymptomatic distant metastases were eligible if local control was judged clinically necessary by the investigator; however, head and neck reirradiation was not permitted. The treatment schema is presented in Figure. Given the negligible toxicity of EGFR-AS injections at any dose during the phase 1 monotherapy trial, the highest dose of 1.92 mg/1.92 mL was selected for development in combination with cetuximab and RT. Treatment duration was 9 weeks. Cetuximab was administered as a loading dose of 400 mg/m2 intravenously during week 1 followed by 250 mg/m2 per week during weeks 2 through 9. Starting at week 1, EGFR-AS was injected weekly into the selected lesion for 7 weeks or until patients attained a complete response (CR). Patients underwent computed tomography-based treatment planning with intensity-modulated RT. The total radiation dose to gross disease was from 70 to 74 grays administered at 2 grays per fraction over 7 weeks starting at week 3. All locoregional disease was incorporated within the radiation field; distant metastases, if present, were not treated with radiation therapy. Clinical grade pNGVL1-U6-EGFRAS (EGFR-AS) was produced under good manufacturing practice conditions at the Center for Biomedicine and Genetics at the City of Hope (Duarte, Calif) to the City of Hope?s Master File BB-MF-9778, as previously described. Funding for drug manufacture was provided by the National Institute of Health?s National Gene Vector Laboratory (NGVL) program. Pretreatment and posttreatment tumor specimens were obtained from the injected lesion at the time of diagnostic evaluation and after 2 doses of EGFR-AS and cetuximab, before the initiation of RT. A representative portion of each tumor was snap frozen. A reverse-phase protein array was performed on lysates from snap-frozen specimens, as previously described. This phase 1 trial was designed to enroll 11 patients to a fixed-dose combination of intratumoral EGFR-AS, cetuximab, and RT. Because no grade 2 or higher adverse event (AE) was observed during phase 1 development of intratumoral EGFR-AS, the highest previously tested dose of EGFR-AS was implemented without a plan for further escalation. The primary objective was to evaluate safety. The primary endpoint was DLT, defined as any grade 3 or 4 AE according to the National Cancer Institute Common Toxicity Criteria for Adverse Events, version 4.0 at least possibly related to EGFR-AS. The design sought to rule out an unacceptable DLT rate ?20%. If no grade 3 or 4 AEs caused by EGFR-AS were observed, then the upper 90% confidence bound for the DLT rate would be <20%. Locoregional RECIST responses were categorized by computed tomography scans obtained 8 to 12 weeks after the completion of RT. To qualify for a lesional CR, complete disappearance of the injected lesion was required. To qualify for a locoregional CR, complete disappearance of all locoregional disease within the radiated head and neck field was required. In patients with stage IVC disease, distant metastases were not included as target lesions when assessing lesional and locoregional response. Publisher Copyright: {\textcopyright} 2018 American Cancer Society",
year = "2018",
month = oct,
day = "1",
doi = "10.1002/cncr.31651",
language = "English (US)",
volume = "124",
pages = "3881--3889",
journal = "Cancer",
issn = "0008-543X",
publisher = "John Wiley and Sons Inc.",
number = "19",
}