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control. Clinical Pharmacological Studies. The pharmacokinetic behavior of. IDR was examined using a HPLC method adapted from that of Peng. 2990. Research. ... Compounds were de tected by fluorescence, using excitation and emission wavelengths of. 47
Departments of Medicine [J. L, A. T. H.. W. D. B., C. J.. .... abbreviations used are: ..... ftn. QJ . ÃâU. uÃÅ 60 i. 40. 5 et. 20 Ã¢â¬Â¢ "' Ã¢â¬Â¢IO Ã¢â¬Â¢121. 16)- Ã¢â¬Â¢141. 131.
long-term venous access catheters has made prolonged infusion of vinblastine and ... 3The abbreviations used are: CVI, continuous vinblastine infusion; VLBÃÂ«, steady-state serum ..... N. Engl. J. Med., 291: 127-133, 1974. 18. Ratain, M. J. ...
AZD7762, a novel checkpoint kinase inhibitor, drives checkpoint abrogation and potentiates DNA-targeted therapies. Mol. Cancer Ther. 2008;7(9):2955-66. 44.
(Milford,. MA) as well as a Spectroflow. 980 programmable fluorescence detector. (Kratos. Division, ...... E. M., Pajak, T. F., and Bateman,. J. R. Adriamycin given.
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(/')determined the human pharmacokinetics of the drug on a. 6-h infusion ..... dexamethasone, and/or aminophylline were required to treat the reactions.
POH was formulated in soft gelatin capsules con- .... Drug Formulation. ... phase I design. .... No significant problems with myelosuppression were seen. Grade 1 ...
Phase I and Clinical Pharmacology Study of Intravenous Flavone Acetic Acid. (NSC347512)1 .... tration was achieved by evaporation under nitrogen. A standard ...
Antisense Oligonucleotide ISIS 3521 Administered in Combination with 5-Fluorouracil and Leucovorin in Patients with. Advanced Cancer1. Sridhar Mani,2 ...
staurosporine family of agents, which have two indole nitrogens linked to a carbohydrate residue. Representatives from both of these subgroups have been the ...
to the antifolate drugs trimetrexate, metoprine, homofolate, and CB3717 in human lymphoma and osteosarcoma cells resistant to methotrexate. Cancer. Res.
infusion solutions are compatible with PVC i.v. infusion bags and are chemically stable ... two cycles of treatment. Disease assessments by any tech- ...... Click on "Request Permissions" which will take you to the Copyright Clearance Center's.
Jan 15, 1994 - Phase I and Pharmacological Study of the Novel Topoisomerase I Inhibitor .... to the aqueous insolubility of the closed-ring CPT lactone (1-7). ... O2CH 3. SN-38. Fig. 1. Structures of CPT-11 and SN-38. To date, phase I and II trials o
9-AC,3 9-nitrocamptothecin, topotecan, irinotecan, karenitecin, and DX-8951f ... of 12 weeks, adequate bone marrow reserve (defined as ab- solute neutrophil ...
them, to break down all of the components of the ECM, includ- ing the basement membrane (1). ... novel synthetic hydroxamic acid derivative (Fig. 1) able to .... (free base). 1913 ..... We wish to thank Drs. T. S. Ganesan and N. Dobbs (Imperial.
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anemia, and brief transaminasemia. One patient who received antibody alone had an apparent acute immune complex-mediated reaction. Ten of. 11 patients ...
C.P. Thakur, S. Narayan* & A. Ranjan* ..... editors. A hand book of tropical diseases, 6th ed. Calcutta: ... Thakur CP, Singh RK, Hassan SM, Kumar R , Narain S,.
Heinrich, M. C. SU5416 and SU5614 inhibit kinase activity of wild-type and mutant FLT3 receptor tyrosine kinase. Blood, 100: 2941â2949,. 2002. 8. O'Farrell ...
[CANCER RESEARCH 55, 3060-3067,
July 15, 1995]
Phase I Clinical and Pharmacological Study of Suppression of Human Antimouse Antibody Response to Monoclonal Antibody L6 by Deoxyspergualin1 Kapil Dhingra,2 Herbert Pritsche, James L. Murray, Albert F. LoBuglio, M. B. Khazaeli, Susan Kelley, Mark A. Tepper, Dennis Grasela, Aman Buzdar, Vicente Valero, Daniel Booser, Hannah Whealin, Tedd J. Collins, Janice M. Pursley, and Gabriel Hortobagyi Departments of Breast Medical Oncology Â¡K.D., A. B.. V. V., D. B., H. W., G. H.Â¡,Laboratory Medicine Â¡H.F.], and Clinical Immunology and Biological Therapy [J. L M.], The University of Texas M. D. Anderson Cancer Center. Houston, Texas 77030; Comprehensive Cancer Center. University of Alabama at Birmingham. Birmingham. Alabama 35294 Â¡A.F. Ã•-,M. B. K.]; and Departments of Cancer Clinical Research Â¡S.K.. M. A. T.Â¡and Human Pharmacology Â¡D.G.. T. J. C.. J. M. P.], Bristol-Myers Squibb Company. Wallingford. Connecticut 06492
immune response, i.e., HAMA3 response. HAMA may be directed
against the constant region (anti-isotypic), the variable region (antiidiotypic), or the antigen-binding region (antiparatopic) of the murine antibody. The clinical consequence of the HAMA response is an impaired localization of subsequently administered murine antibody to the target due to increased clearance from the circulation as a result of immune complex formation between the antibody and HAMA (10-13). Circulating HAMAs can also interfere with assays for tumor
Development of human antimouse antibody (HAMA) is a major limit ing factor in the application of murine ni Ali for clinical use. A novel immunomodulatory drug, deoxyspergualin (DSG), has shown potential to suppress antimouse antibody response in preclinical model systems. We conducted a Phase I trial to determine the effect of DSG on HAMA response to murine m Ab L6 administered to patients with advanced cancers (in previous trials, this antibody elicited HAMA in two-thirds of
markers (14, 15). Furthermore, readministration of mAbs to such presensitized individuals may result in an anamnestic response and allergic reactions, including serum sickness (16). Therefore, HAMA response has been one of the major impediments in exploration of the therapeutic potential of mAbs. L6 is an IgG2a murine mAb which recognizes a 24-kDa antigen
INTRODUCTION The ability to selectively target defined cell populations has led to an expanding investigation of the potential role of mAb for diagnosis and therapy of neoplastic as well as nonneoplastic conditions (1-8). The majority of mAbs tested in clinical trials to date have been developed by hybridoma technology involving fusion of malignant plasma cells with B lymphocytes derived from mice immunized with the relevant antigen (9). The human immune system recognizes mu rine mAbs as alloantigens and reacts by mounting a classical humoral
(17) that is expressed on the surface of most human adenocarcinoma and non-small cell lung carcinoma cells (18). The antibody is capable of mediating antibody-dependent cellular cytotoxicity and comple ment-dependent cytotoxicity in vitro (18). In two previous Phase I studies [one using L6 alone (19), and another using a combination of L6 and interleukin 2 (20)], administration of L6 induced an antiisotypic HAMA response in approximately two-thirds of the patients treated (13/18 and 9/14, respectively). Anti-idiotypic antibodies were measured in only the first of these trials and were detected in 8 of the 13 patients who developed HAMA. The incidence of HAMA response did not appear to be dose related. HAMA typically appeared around day 14, although in one case, it was first detected 70 days after the initiation of treatment. DSG is a derivative of spergualin, a fermentation product isolated from Bacillus laterosporus (21). This compound has demonstrated the ability to block humoral immune response to both T-cell-dependent as well as T-cell-independent antigens (22). It inhibits the antibody response to highly immunogenic proteins including keyhole limpet hemocyanin, sheep RBC antigens, and pseudomonas exotoxin immunoconjugates (23-25). In numerous animal organ transplant models, DSG has been shown to suppress graft rejection when administered at the time of transplantation as well as when used to reverse established acute allograft rejection (26-29). Animal studies also suggest immunosuppressive activity in models of autoimmune diseases, including rheumatoid arthritis, systemic lupus erythematosus, and multiple scle rosis (30-34). Initial clinical trials in humans also suggest efficacy in the treatment of clinical graft rejection (35-38).
Received 2/3/95; accepted 5/12/95. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. 1 Supported in part by the Bristol-Myers Squibb Company and the National Cancer Institute. K. D. is a recipient of a Clinical Oncology Career Development Award from the American Cancer Society. Preliminary results of this trial were presented at the 5th International Workshop on Breast Cancer Research and Immunology, November 1992, and the Annual Meeting of the American Society for Clinical Oncology, May 1993. 2 To whom requests for reprints should be addressed, at Department of Breast Medical Oncology, Box 56, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030.
The ability of DSG to suppress immune response to alloantigens led us to design a Phase I study to investigate its potential to suppress HAMA response to murine mAb L6. The results of this trial suggest a marked suppression of the HAMA response as compared to the historical experience with this mAb. 3 The abbreviations used are: HAMA, human antimouse antibody; AUC, area under the serum concentration versus time curve; dl, dose level; DSG, deoxyspergualin; clearance; QCs, quality control specimens; IL, interleukin.
mg/m2 (days1-7)50 6 wk 150150ScheduleEvery Every 6 wk Every 3 wk
Blood samples were obtained for HAMA measurement every 2 weeks during the period of study and monthly thereafter for at least 3 months. Because of the diversity of HAMA that may be generated following murine mAb administration, we used two different assays to quantitate the HAMA level. The first assay used was a standard ELISA, which is available as a commercial kit (ImmuSTRIP; Immunomedics, Inc., Warren, NJ). This assay utilizes polyclonal mouse immunoglobulin as an antigen and, thus, detects HAMA to murine constant regions. The results of the assay are compared to a standard curve generated with an affinity-purified primate antimouse immu noglobulin and reported as ng/ml antibody "equivalents." The lower limit of sensitivity of this assay is reported to be 37 ng/ml antibody equivalents and a positive assay is defined as Â£74 ng/ml according to the manufacturer's instructions. The second assay used was a radiometrie assay, which also uses a "doubleantigen" format but differs from the ELISA assay in that the murine LÃ²is used as the antigen, and, thus, HAMAs to both the constant (isotypic) and variable (idiotypic) regions of murine L6 are detected. The results of this assay are reported as ng L6 bound/ml/serum. Samples from 18 normal donors studied using this assay had a mean binding value of 9 (Â±5) ng/ml. Hence, a positive radiometrie assay was defined as an anti-L6 antibody level of >19 ng/ml (i.e., greater than 2 SD above normal). Pharmacokinetic
In consenting patients, blood samples for assay of L6 and DSG content were obtained immediately before and after completion of DSG and L6 infusions on days 1, 2, 5, 6, and 7. In addition, on days 1 and 5 (first and last day of L6 dosing), samples were obtained for L6 determination at 1, 2, 4, and 6 h after completion of mAb infusion. Similarly on days 1 and 7 (first and last day of DSG dosing), samples were obtained for DSG pharmacokinetic analysis at 0.5, 1, 2, 3, 4, 5, 6, and 7 h after completion of infusion. A final sample for L6 and DSG assay was collected 24 h after the last dose of DSG. The blood was collected in anticoagulant-free tubes, left at room temperature for 30 min to clot, and then centrifuged. The sera were immediately frozen at -20Â°C in polypropylene tubes and batched for analyses. L6 Assay. The serum concentration of L6 mAb was determined by a double anti-idiotypic antibody sandwich ELISA. The method utilized a murine mAb IB with idiotypic specificity for L6 as the capture antibody. L6 was then detected using a second L6-specific biotinylated anti-idiotypic mAb 13B followed by avidin-linked horseradish peroxidase and a chromogenic substrate. Standards were prepared on the day of each analytical run and were assayed in duplicate in a range of 5-50 ng/ml. QCs prepared on the day of each analytical run and those stored with clinical specimens, at nominal concentrations of 10, 100, or 1000 ng/ml, were diluted to the lower and upper range of the standard curve and analyzed in duplicate with the study specimens. All standard curves had r2 values of >0.96. The overall accuracy, based on the mean percentage of deviation from nominal for the OCs, ranged from 0 to 10% of the nominal value of 10 /ng/ml, 0 to 13% of the nominal value for 100 ng/ml, and 0.5 to 17% of the nominal value for 1000 /xg/ml. The overall within-run precision was <9% and the between-run precision was <8%. DSG Assay. The serum concentration of DSG was determined by a vali dated HPLC assay. Extraction of DSG and the internal standard, /V-(8-guanidinoctanoyl)-a-hydroxyglycyl spermidine, from serum samples was accom plished by means of carboxylic acid-2 solid-phase extraction columns. Chromatographie separation was performed using a Zorbax Rx C8 analytical column with a mobile phase of acetonitrile and aqueous buffer (0.01 M KH2PO4, 0.005 M heptanesulfonic acid and sodium EDTA at pH 3.0) in a ratio of 80.5:19.5. Analyte detection was accomplished by post-column derivatization using o-phthalaldehyde and fluorescence detection (excitation and emis sion wavelength of 340 and 455 nm, respectively). Standard curves were linear over a concentration range of 5-1000 ng/ml. All standard curves had r2 values of >0.992. The overall accuracy, based on the mean percentage of deviation from nominal for the QCs (analytical and shipping), was <8.2%. The overall within-run precision was <7.1% and the between-run precision was <16.5%. Pharmacokinetic parameters for DSG and L6 were calculated from serum concentration versus time data by noncompartmental methods (41) using the MENU program (42). The highest observed serum concentration was defined
as Cmax. The AUC from 0 to 24 h after the start of the L6 infusion (AUCo^24) was estimated by the trapezoidal rule. The total AUC (AUC()_^Â»)for DSG was estimated by adding the AUC from time 0 to the last measureable serum concentration (C,), estimated by trapezoidal rule, and the AUC from C, to infinity, estimated by the quotient of C, and the terminal elimination rate constant (Az). The terminal elimination rate constant was computed as the absolute value of the slope of a least-squares regression of the natural logarithm of serum concentration versus time in the elimination drug disposition. The r1/2 was computed using the following f,/2 = 0.693AZ. The CL of DSG was computed using the following CL = Dose/AUC,, .Â».The volume of distribution at steady-state
phase of equation: equation: (V5S) was
computed using the following equation: Dose * AUMC,,_
Dose * 7" *2
where Dose is the total amount of drug infused, AUMC,,^^ is the area under the (first) moment serum concentration versus time curve, and T is the infusion duration.
DAY ON STUDY An important objective of this Phase I trial was to determine a potentially effective dose of DSG for suppression of HAMA (dose-limiting toxicity was not expected to occur at the doses used). A two-stage study design was used at each dl. Three patients were initially treated at each dl. If Ã¤2 of 3 patients developed HAMA, that dl would be declared ineffective and accrual would begin at the next highest dl. If < 2 of 3 patients developed HAMA, five additional patients were treated at that dl. If > 4 of 8 individuals developed HAMA, that dl would be declared ineffective. We considered a reduction of HAMA incidence from 66% (historical experience) to 20% to be of potential clinical significance. Therefore, with the first stage of trial design (i.e., 3 patients), there was only a 10% chance of a false-negative result (i.e., declaring
Fig. 1. Kaplan-Meier plot of HAMA as determined by the ELISA (ImmuSTRIP) assay. There was a statistically significant suppression of HAMA (log rank P = 0.0001) response to L6 by DSG when the results of Ihe current study (â€”) were compared with historical controls (â€”). Each circle, one individual censored on the corresponding day.
an effective dl to be ineffective). Overall, stage 1 and II (i.e., total of eight patients) design provided a probability of 0.08 of accepting a dl that is ineffective (false-positive error) and a probability of 0.06 of rejecting a dl (false-negative error) when the actual HAMA incidence is 20%. It should be
1650,790, 207,24,442150 129, 153, 183, " Results of the two assays are not directly comparable on a ng to ng basis (see text).
DAY ON STUDY Fig. 2. Kaplan-Meier plot of HAMA as determined by the radiometrie assay. There is a trend toward suppression of anti-L6 antibody response when the results of the current study (â€”) are compared with historical controls ( ). Each circle, one individual censored for follow-up on the corresponding day.
respectively) were detected to have anti-L6 antibodies using this assay (Table 3). The median time to positivity was 82 days, and the median highest serum level of anti-L6 antibodies was 129 ng/ml (range, 21-2150). [The reader is cautioned that the results of the two assays are not equivalent on a ng to ng basis due to differences in the methods for quantitation of HAMA (see "HAMA Assays" in "Patients and Methods")]. It is noteworthy that in the three patients at dl III who
Table 4 Anli-idÃ¬otypicversus anli-isolypic anti-ltl murine mAb response
developed anti-L6 antibodies, the highest circulating levels of these antibodies were 44, 24, and 21 ng/ml, respectively (as compared to highest levels of 40-2150 ng/ml at dis I and II). Thus, there is a suggestion that dl III may be more efficacious than dl I or II for suppression of HAMA. The radiometrie assay had not been used to detect HAMA in previous trials of murine L6 mAb. However, because of the apparent discrepancy between the ELISA and the radiometrie assay results in the current study, we retrospectively analyzed frozen serum samples from individuals treated in one of the previous studies of L6 mAb (Ref. 20; these samples were in storage for approximately 2 years and had previously been analyzed using the same ELISA as used in the current trial). Eight of these 14 individuals were detected to have anti-L6 antibodies. The median time to detection of anti-L6 antibodies was 25 days. It should be noted that in the previous study, only one patient received more than one course of L6 treatment. In contrast, 15 of the 24 patients (including 8 of 8 individuals at dl III) received multiple courses of treatment in the current trial. Furthermore, in the previous trial, patients were routinely followed only up to 8 weeks from initial L6 mAb administration. Therefore, delayed occurrence of HAMA would have been missed. In contrast, the median follow-up in the current study was 18 weeks. In 4 of the 13 individuals who developed HAMA detected by the radiometrie assay in the current study, anti-L6 antibodies first appeared in the circulation after 8 weeks. Such individuals could easily have been missed in the previous studies due to shorter follow-up. Additional support for this possibility comes from the observation in previous trials that the HAMA re sponse to the variable region of L6 is frequently delayed as compared to the HAMA against the constant region (19). Thus, with the con straint of the well-recognized limitations of historical controls, it appears that DSG can delay and possibly suppress anti-idiotypic HAMA as well (Fig. 2).
weeks. C3 decreased from a basal level of 144 Â±29 to 101 Â±18, an average drop of 30% (P = 0.0001). Similarly, CH50 dropped from a pretreatment level of 146 Â±63 to 12 Â±13. Thus, DSG did not appear to interfere with complement activation that is known to follow L6 mAb administration. Because of concerns about the potential for generalized immuno-
suppression by DSG, all patients underwent serial monitoring of quantitative immunoglobulins as well as peripheral blood lymphocyte subsets. Mean (Â±SD) serum IgG, IgA, and IgM levels were 1164 Â±479, 213 Â±92, and 110 Â±74 mg/100 ml, respectively, prior to treatment, while the corresponding posttreatment levels were 1145 Â±473, 205 Â±82, and 108 Â±80 (P > 0.05 for each). Mean T4:T8 ratios before treatment at dis I-III were 1.08 Â± 0.28,
14 16 18 20 22 24
Week on Study Fig. 3. Serial change in T4:T8 D) (P > 0.05 for dis I and II, and
T4:T8 ratios during L6 and DSG therapy. There was no significant ratios during the period of study at dis I (â€¢-,O), II (- -, 0), or III (â€”, each). (Note lhat the treatment courses were repeated every 6 weeks at every 3 weeks at dl III.)
1.48 Â±0.63, and 0.96 Â±0.52, respectively, while the corresponding end of study values were 0.90 Â±0.20, 1.33 Â±0.69, and 1.00 Â±0.45, respectively (P > 0.05 for each dl; Fig. 3). Similarly, there were no significant changes in pre-B, natural killer, or the precursor T cells (data not shown). There were no instances of opportunistic and/or unusual infections. Thus, at the doses used, DSG did not appear to induce a generalized immunosuppression, at least none that could be detected clinically or with the limited immunophenotypic analysis carried out in this study. Pharmacokinetics. Pharmacokinetic sampling was performed dur ing and after at least one course of therapy in 18 patients. Of the 15 patients who received two or more courses of chemotherapy, pharmacokinetic data from at least two courses are available for 7 patients. L6 mAb Pharmacokinetics. The mean terminal i,/2 of L6 was 52 h (range, 25-150 h) following the first course of therapy. This result is consistent with the previously reported value of 30 (range, 20-40) h for comparable doses of L6 mAb (19). These findings suggest that accumulation of L6 in the serum from one course to the next is unlikely. The individual pharmacokinetic data for L6 mAb in the seven
Table 6 Multiple course murine mAb L6 pharmacokinelics L6 was administered as a 1-hr infusion for 5 days. _ 24 (h)Day (mg-h/liter)
patients in whom L6 pharmacokinetics could be determined for two courses are shown in Table 6. (The majority of individuals at dis I and II progressed during the 6-week waiting period after the first course of
humanized) antibodies (45, 49). Even chimeric and humanized anti bodies may be associated with the development of an antiallotypic or anti-idiotypic host immune response to the therapeutic antibody (45,
treatment and, therefore, multiple course pharmacokinetics was not possible.) The day 5 AUC0 ,24 values decreased in 5 patients (range, 4-54%) and increased in 2 patients (4% and 29%) when course 1 was
50). The results of our study suggest that DSG may suppress and/or delay HAMA response. Even in patients who developed HAMA, the levels were so low that the CL of the antibody was not impaired at the doses used. Furthermore, the HAMA response was delayed as com pared to the historical experience with L6 and other murine mAbs. Such a delay in the onset of HAMA may be sufficient to allow administration of multiple courses of the antibody being tested. We made a concerted effort to follow-up on patients for delayed devel
compared to course 2. However, in the patient with the largest decrease in AUC()_^24 value, the tl/2 values did not change signifi cantly, suggesting that factors other than a change in clearance may be responsible. Of the seven patients in whom multiple-course pharma cokinetics could be performed, two had positive HAMA [one by both the assays (patient 2, highest HAMA level 160 ng/ml using the ELISA and 1650 ng/ml using the radiometrie assay) and another by the radiometrie assay alone (patient 17, highest HAMA level 44 ng/ml)]. Interestingly, the half-life of L6 was not significantly changed in patient 2 but was shortened considerably in patient 17. Whether this decrease can definitely be attributed to the low level of HAMA is difficult to ascertain because significant changes in half-life were observed between the first and second course even in patients who did not develop HAMA detectable using either assay (e.g., patient 20 in Table 6). DSG Pharmacokinetics. The pharmacokinetics of DSG appeared first-order based on the log-linear plots of the serum concentration versus time data. Following i.v. administration, the disappearance of DSG from the circulation appeared biexponential. There is a rapid initial distribution phase followed by a slower terminal phase with a i,/2 of approximately 1.8 h. Mean (Â±SD) pharmacokinetic parameters values for DSG are provided in Table 7. An approximately 3-fold increase in Cmajt and AUC,, ,Â«values was observed for a 3-fold increase in dose (from 50 mg/m2 to 150 mg/m2), suggesting the pharmacokinetics of DSG are linear over this dose range. CL, Vss,and i,/2 were independent of dose and were comparable from days 1 to 7 and from course 1 to course 2, suggesting that the pharmacokinetics of DSG are stationary following multiple-dose administration. The intersubject variability in the pharmacokinetic parameter values for days 1 and 7, for courses 1 and 2, averaged about 30% (range, 5-135%). DISCUSSION The development of HAMA response to murine mAb has been a major obstacle in realizing the clinical potential of mAb. Most ap proaches used to date for suppression of HAMA have been ineffective and/or toxic (16, 46-48) or required considerable investment of time and financial resources to develop novel, less immunogenic (chimeric,
opment of HAMA, up to several months after the last mAb treatment. For example, the mean follow-up in our study was more than twice as long as in the two previous studies. Thus, the true historical HAMA incidence may actually be higher than that used for comparison to the current study. It should be noted that the half-life of the L6 mAb is quite long (52 h) in contrast to the 1.8-h half-life of DSG. Thus, during the treatment period, on a daily basis, DSG disappeared from the circulation while the circulating levels of L6 mAb remained quite high. Furthermore, although we administered DSG for 2 additional days following the last dose of L6, significant circulating levels of L6 were present for several days thereafter. In target tissues, L6 can be detected as late as 2-3 weeks after treatment (19). Thus, it would appear that DSG induced a state of tolerance in the immune system that blocked responsiveness to L6 mAb even when no circulating DSG was pre sent. This hypothesis is supported by the results of recent studies showing induction of a state of tolerance by DSG in mice treated with a hamster anti-mouse CD3 antibody (2C11) (51). The precise mechanisms that underlie HAMA suppression by DSG are not completely understood. In numerous laboratory models, DSG has been shown to suppress humoral and cell-mediated immune responses to both alloantigens and autoantigens (22-32). Its mode of action appears to be quite distinct from that of other immunosuppressives such as cyclosporin A and FK506 (52-54). For example, DSG blocks IL-1 synthesis in inflammatory cells (55) but does not inhibit IL-2 synthesis and has only minor effects on the expression of IL-2 receptors (52). Interestingly, DSG can prevent primary nonfunction of pancreatic islet xenografts (a phenomenon that is believed to be related to macrophage activity), suggesting a unique effect of DSG on the macrophages as compared to other immunosuppressive agents (28). Like cyclosporin A, DSG can suppress precursors of CTLs but the suppression cannot be reversed by IL-2. More recently, DSG has been shown to bind to HSC 70, a member of the heat shock protein 70
Table 7 Mean lÂ±SD) DSG pharmacokinetic
(ng-h/ml)Day 7DSG Coursecmâ€ž(ng/ml)Day 1AUCo_ wkMeanSDn1DSG 50 mg/m2, daily X 7 days every 6
dailyMeanSDnDSG 150 mg/m-,
wk24496214X 7 days every 6
mg/m2.MeanSDnMeanSDn1daily127291235X 150 7 days wk1994354715695176584105519(1653731922155714295473159827055483167444722780744201686613913015434310203493096573279125531.260.4751.530.6551.450.3472.8 every 3
family (56). Members of this family are believed to be involved in antigen processing and presentation. Another activity that is probably more relevant to HAMA suppression is the ability of DSG to block differentiation of human B lymphocytes into immunoglobulin-producing cells, without inhibiting cell proliferation, in both T-celldependent and T-cell-independent systems (57). However, further studies are needed to determine the exact mechanism of HAMA suppression by DSG. Caution should be exercised in interpreting the results of our study. Because of a lack of an extensive historical data base on HAMA responses for L6 mAb, we relied on prior experience with this mAb in Phase I studies. By and large, the historical incidence and time course of appearance of HAMA with this mAb is similar to the experience with most other murine mAbs given to comparable groups of patients (11, 13, 46). Therefore, we believe the prior L6 mAb experience to represent a reliable historical control. Also, a variety of different assays have been used to detect HAMA, and the results obtained using these various assays are not directly comparable. For example, the results of both the assays used by us are reported in ng/ml but neither one of them reflects an absolute HAMA titer (see "Patients and Methods" and "Results"). The HAMA response is clinically significant if it interferes with the delivery of the mAb to the target or leads to adverse clinical side effects. The patients who developed HAMA in our study had low levels (ng) of circulating antimouse antibodies and the dose of L6 mAb was quite high (mg). When a lower dose of mAb is administered [e.g., imaging studies (58)], even these low HAMA levels could become clinically or pharmacokinetically relevant. It could be argued that patients with advanced cancers may be immunosuppressed and, therefore, may not be capable of mounting a HAMA response. We do not believe this to have been the reason for the observed lack of HAMA response since similar patients treated in previous studies by us and others (19, 20, 45) have developed HAMA at a high frequency. HAMA-suppressing agents, if effective, are expected to be used as
vation of complement. No significant decreases in lymphocyte counts were observed. In early studies in animal tumor models, administra tion of DSG has not resulted in reduction of antitumor activity of immunotoxins.4 However, further studies are necessary to ensure that DSG would not interfere with antitumor immune effector mechanisms in humans. The findings obtained in this Phase I study with the novel drug DSG are encouraging. The ability to suppress the immune response to new antigens raises important possibilities not only for oncological and nononcological (e.g., sepsis, graft rejection) applications of mAb, but also for a wide variety of autoimmune and alloimmune diseases in which persistent and/or exuberant activation of the immune cascade leads to deleterious consequences. Further trials of DSG to confirm HAMA suppression as well as to modulate autoimmune responses are warranted. This study also reinforces the need to use more than one HAMA assay in clinical trials of murine mAb to adequately assess the HAMA response. ACKNOWLEDGMENTS We wish to thank Judy Vance for preparation of the manuscript and Lia Gutierrez and Josie Victorian for assistance with data analysis.
adjuncts to mouse mAb therapy rather than be used as primary anticancer therapy. Therefore, although our study was a Phase I trial, the primary objective was to define a potential biologically active dose with acceptable toxicity rather than define a maximally tolerated dose of the combination. Our initial study plan was to escalate the dose of DSG to 250 mg/m2/day at dl III, while keeping the interval between courses at 6 weeks. However, based on the experience at the first two dose levels, the protocol was amended to the dl III indicated in Table 1. This decision was based on two reasons: (a) there did not appear to be a clear dose response between the dose of DSG and HAMA at dis I and II, and (b) the majority of individuals progressed in the 6-week interval between the first and second course at dis I and II. This, coupled with the observation that the toxicity of the combi nation did not persist beyond 3 weeks, made it ethically and scientif ically more desirable to change the interval between treatments to every 3 weeks rather than escalate the dose of DSG to 250 mg/m2/day (which is close to the maximum tolerated dose of DSG given as a 3-h infusion). It is conceivable that higher doses of DSG or a continuous infusion schedule may be more effective in suppressing HAMA. However, based on our experience in this trial, we would recommend a starting Phase II dose of 150 mg/m2/day, with provisions for dose escalation for individuals who develop HAMA at this dose until comparative trials can demonstrate that higher doses of DSG are clearly more beneficial. Occasional partial responses have been observed in previous stud ies with L6 mAb. No patient in our study had any significant tumor shrinkage. Given the Phase I nature of this study, we cannot draw any definite conclusions about potential interference with immune effector mechanisms by DSG. All patients showed rapid and prolonged acti
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Phase I Clinical and Pharmacological Study of Suppression of Human Antimouse Antibody Response to Monoclonal Antibody L6 by Deoxyspergualin Kapil Dhingra, Herbert Fritsche, James L. Murray, et al. Cancer Res 1995;55:3060-3067.
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