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© 2002 American Society for Clinical Oncology Phase I Trial of Intravenous Administration of PV701, an Oncolytic Virus, in Patients With Advanced Solid CancersByFrom the Cancer Center at Hackensack University Medical Center, Hackensack, NJ; Lombardi Cancer Center, Georgetown University Medical Center, Washington, DC; The Cancer Center at Greater Baltimore Medical Center, Baltimore, and Pro-Virus, Inc, Gaithersburg, MD; and Fox Chase Cancer Center and University of Pennsylvania Medical Center, Philadelphia, PA. Address reprint requests to Andrew L. Pecora, MD, Hackensack University Medical Center, Northern New Jersey Cancer Center, 20 Prospect Ave, Suite 400, Hackensack, NJ 07601; email: apecora@ humed.com.
PURPOSE: PV701, a replication-competent strain of Newcastle disease virus, causes regression of tumor xenografts after intravenous administration. This phase I study was designed to define the maximum-tolerated dose (MTD) and safety of single and multiple intravenous doses of PV701 as a single agent in patients with cancer. PATIENTS AND METHODS: Seventy-nine patients with advanced solid cancers that were unresponsive to standard therapy were enrolled. Four PV701 intravenous dosing regimens were evaluated: (1) single dose: one dose every 28 days; (2) repeat dose: three doses in 1 week every 28 days; (3) desensitizing: one lower dose followed by two higher doses in 1 week every 28 days; and (4) two week: one lower dose followed by five higher doses over 2 weeks every 21 days. RESULTS: A 100-fold dose intensification was achieved over 195 cycles. A first-dose MTD of 12 x 109 plaque-forming units (PFU)/m2 was established for outpatient dosing. After an initial dose of 12 x 109 PFU/m2, patients tolerated an MTD for subsequent doses of 120 x 109 PFU/m2. The most common adverse events were flu-like symptoms that occurred principally after the first dose and were decreased in number and severity with each subsequent dose. Tumor site–specific adverse events and acute dosing reactions were also observed but not cumulative toxicity. Objective responses occurred at higher dose levels, and progression-free survival ranged from 4 to 31 months. Tumor tissue from one patient was obtained after 11 months of therapy and showed evidence of PV701 particles budding from the tumor cell membrane by electron microscopy and a pronounced lymphoplasmacytic infiltrate by histologic examination. CONCLUSION: PV701 warrants further study as a novel therapeutic agent for cancer patients.
PV7011,2 IS A HIGHLY purified, replication-competent, naturally attenuated strain of Newcastle disease virus,3-6 an avian paramyxovirus. Newcastle disease virus strains, such as PV701, directly lyse diverse human cancer cells in vitro (oncolytic) while being significantly less toxic toward normal human cells.1,3,7 Moreover, the virus is capable of both stimulating T-cell–mediated specific antitumor immunity and inducing nonspecific activation of immune function, such as the induction of cytokines (eg, interferon) and activation of tumoricidal macrophages.8-10 Newcastle disease virus is a rapidly replicating RNA virus with progeny virions first detectable in vitro within 3 hours after infection. After infecting a cancer cell, the virus rapidly spreads to neighboring tumor cells through the release of progeny virions and syncytia formation.3,11 PV701 and certain other negative strand RNA viruses are selectively cytolytic for tumor cells as a result of defects in the interferon (IFN) signaling pathway that are common among diverse tumor types.12,13 Defects in this pathway are believed to confer a growth and survival advantage to tumor cells.13-16 However, these tumor defects also disable the antiviral function of IFN and confer sensitivity of malignant cells to infection and replication of viruses such as PV701.
Oncolytic Newcastle disease virus strains, including PV701, administered via intravenous, intraperitoneal, and intratumoral routes, replicate selectively in human cancer cells implanted in athymic mice, resulting in high rates of complete tumor regression and sparing of normal tissue.2,3,17,18 In vitro death for most tumor cell lines occurs at a PV701 amount Oncolytic activity associated with Newcastle disease virus was first observed by Cassel and Garrett19 when an intratumoral injection in a patient with cervical cancer resulted in tumor regression of the injected mass as well as a supraclavicular lymph node metastasis. Subsequent clinical trials of Newcastle disease virus focused primarily on a vaccine approach using viral oncolysates that included low doses of viable virus infecting autologous tumor cells.8,20,21 Characteristics of Newcastle disease virus that are favorable for human trials include the genetic stability of vaccine strains, the absence of genetic recombination, lack of a carrier state of naturally attenuated strains, and the lack of antigenic drift.3 Human-to-human transmission has not been observed.6 The virus has been safely given to humans in tumor vaccine studies, and accidental exposure has been reported to cause only self-limiting conjunctivitis.3,5,6 Other replication-competent viruses, including adenovirus and herpes simplex virus alone or in combination with chemotherapy, have caused tumor regressions in humans by the intratumoral route.22-24 Early testing of both replication-competent and replication-incompetent adenoviruses by the intravenous route has been initiated,25,26 but, until now, there has been no determination of the MTD for systemic therapy with a virus. Herein we report on a phase I study with dose escalations including the testing of various treatment schedules and MTD determination for systemic (intravenous) administration of the replication-competent virus PV701 in patients with advanced cancer that was unresponsive to standard therapy.
Patient Enrollment Seventy-nine patients were enrolled with advanced or metastatic solid malignancy that was unresponsive to treatment with established therapies. Entry criteria included at least one bidimensionally measurable tumor,  18 years of age, a life expectancy of at least 3 months, and a performance status (Eastern Cooperative Oncology Group) of 0 or 1. Laboratory result minimum entry requirements included 3,000 WBCs/µL, 1,500 neutrophils/µL, and 100,000 platelets/µL. Also required was a serum creatinine level less than 1.5 times the upper limit of normal, serum transaminase level less than 2.5 times the upper limit of normal (< 5.0 times the upper limit of normal for patients with metastatic liver disease), and a therapy-free period of 14 days. Patients were not eligible if documented to have CNS disease (including brain tumors on computed tomography [CT]/magnetic resonance imaging [MRI] scans required at screening), known hypersensitivity to eggs, antiviral or systemic corticosteroid treatment within 14 days, myocardial infarction or life-threatening arrhythmia within 6 months, known positivity for human immunodeficiency virus, active hepatitis B or C infection, an organ allograft, autoimmune disease, active viral infection (including cold or influenza), or uncontrolled bacterial infection. Active poultry workers and pregnant or nursing women were excluded. All patients provided informed written consent approved by the appropriate institutional review board.
PV701
Plaque Assay
Intravenous Administration of PV701
Treatment and Study Design Repeat-dose regimen. Two dose levels were examined (n = 13 patients): either 5.9 x 109 PFU/m2 or 12 x 109 PFU/m2 was administered three times in 1 week every 28 days. Dose 2 was given 2 days after dose 1. Desensitizing regimen. Five dose levels were examined (n = 37 patients): all patients received 12 x 109 PFU/m2 (desensitizing dose) on the first day of administration followed by two doses of 24 x 109 PFU/m2, two doses of 48 x 109 PFU/m2, two doses of 72 x 109 PFU/m2, two doses of 96 x 109 PFU/m2, or two doses of 144 x 109 PFU/m2. Dose 2 was given 2 days after dose 1. For each patient, all three doses were administered within 1 week and repeated every 28 days. Two-week regimen. Two dose levels were examined (n = 12 patients): All patients received 12 x 109 PFU/m2 (desensitizing dose) on the first day of administration followed by five doses of 96 x 109 PFU/m2 or five doses of 120 x 109 PFU/m2. Dose 2 was given 4 days after dose 1. Patients were given three doses per week for 2 weeks (six total doses) followed by 1 week off treatment. Enrollment was for a minimum of two courses. General. Patients were monitored before each treatment and extensively after treatment. Evaluations included physical examinations, measurement of performance status, laboratory parameters, viral shedding (urine and sputum), and serum testing for PV701 antibodies and infectious virus. CT or MRI was used to assess tumor responses after each course of therapy. A minimum of three patients were entered at each PV701 dose level until a patient experienced a dose-limiting toxicity (DLT). When a DLT was encountered, three additional patients were enrolled at that same dose level. There was no further dose escalation when two or more patients experienced a DLT. The MTD was defined as the dose level below that at which two or more DLTs were encountered.
Adverse events were graded using the Southwest Oncology Grading Scale. DLT was defined as a clinically significant adverse event (grade 4 leukocyte or neutrophil count lasting > 5 days; platelet count < 10,000/µL [grade 4 by NCI common toxicity criteria version 2.0]; or All patients were eligible for additional courses of treatment when they had at least stable disease and an acceptable toxicity profile.
Virologic Studies
Neutralizing Antibody to PV701
Cytokine Measurements
Tissue Processing
Statistical Analysis
Patient Characteristics Seventy-nine patients (48 men and 31 women) with advanced cancer that was unresponsive to standard therapy were enrolled onto this study (Tables 1 and 2) from June 1998 through September 1999 and were treated over 12 dose levels with a total of 195 cycles. The median age was 58 years (range, 24 to 81 years) with 22 patients (28%) older than 70 years. The most common primary tumor types were colorectal (n = 23), pancreatic (n = 9), renal (n = 9), breast (n = 8), and non–small-cell lung carcinoma (n = 8). Seventy-two patients had received previous chemotherapy; 35 of them received three or more regimens.
Antibody Response Thirty-two patients were tested at baseline for neutralizing antibody to PV701. One of these patients was positive at the limit of detection of the assay. His adverse event profile was no different from that of other study subjects. The other 31 patients tested all were negative for neutralizing antibody. Fourteen of 16 patients in the single-dose regimen, seven of seven patients in the repeat-dose regimen, and six of six patients in the desensitizing-dose regimen became seropositive, first evident 1 to 2 weeks after PV701 dosing. By week 4 after initial dosing, 10 of 12 patients tested in the repeat-dose and desensitizing regimens had neutralizing antibody titers at 1:320 to 1:640. Eight patients were tested at 5 to 10 weeks after initial dosing, and they had a median neutralizing antibody titer of 1:640 (range, 1:80 to 1:2,560). One patient was followed over 18 courses (1.5 years). At month 3, his titer reached a plateau (at 1:2,560) that has persisted through the last time point analyzed (month 18).
Virology
Cytokines
Toxicity
Two of the first three patients in the first cohort (5.9 x 109 PFU/m2) had grade 3 fever of 40.0°C to 40.6°C, which was promptly reversed with ibuprofen. Beginning with the fifth patient in this cohort, all subsequent patients in this trial received acetaminophen and ibuprofen prophylaxis and the incidence of grade 3 fever was reduced to 11% (eight of 75 patients). In the single-dose regimen, 42% of patients (seven of 17) had at least one episode of diarrhea including one case of grade 4. In subsequent dosing regimens, diarrhea was effectively controlled using loperamide with 10% of patients having diarrhea.
Age and baseline anemia were examined in all 79 patients as potential risk factors for grade 3 flu-like symptoms (fever, fatigue, nausea, vomiting, and dehydration). Age was examined because two DLTs at the 12/144/144 x 109 billion PFU/m2 dose level occurred in elderly patients (81 and 75 years of age; see Dose Escalations, DLT, and Determination of MTD below). Anemia was examined as a risk factor because it might exacerbate the severity of any fatigue, the most common of the grade 3 flu-like symptoms. The analysis showed that 13 (59%) of 22 patients Desensitization to toxicity on repeat dosing. As predicted from the animal models, dose 1 desensitized patients to the flu-like symptoms on subsequent doses. Table 4 lists the six most common adverse events observed for patients in the desensitizing regimen in order of decreasing incidence and by the Southwest Oncology Group severity grade for each dose. Adverse events were reduced in number and severity after the second and third doses despite a two-fold to eight-fold increase in dose. With all patients receiving prophylactic antipyretics, the incidence of grade 3 fever for patients in this regimen was reduced from 13% on dose 1 to being undetected with subsequent doses (Table 4). The incidence of grade 1 to 2 fever reduced from 83% with dose 1 to 17% with dose 3. A similar pattern of desensitization to adverse events was seen in the 2-week dosing regimen with doses 2 to 6 producing milder and less frequent adverse events compared with dose 1, even when doses 2 to 6 were eight- to 10-fold higher (data not shown). This desensitization to toxicity with repeat doses was also seen for the hematologic changes (see Hematology/Coagulation Profiles below). Acute dosing reactions. Acute and reversible dosing reactions were observed in five of the first seven patients enrolled at the 12/96/96 x 109 PFU/m2 dose level, typically during the third dose of the first course. These reactions consisted of back pain, chest tightness, chest pain, and hypertension. Abdominal pain was less commonly seen. In all cases, the onset was within 5 minutes of the start of dosing and resolved spontaneously and completely within 30 minutes of the beginning of the adverse event. In a few instances, these adverse events required a pause in the administration of virus. One patient experienced grade 3 back pain on his third PV701 injection and was the only patient in the study who did not complete a PV701 dosing because of this acute dosing reaction. All other acute dosing reactions were grade 1 or 2. These reactions were attributed to the rate of administration of the virus, which had increased from 1.2 x 109 PFU/m2/min at the 12 x 109 PFU/m2 dose level to 1.0 x 1010 PFU/m2/min at the higher dose levels. In subsequent patients, the administration rate for doses above 12 x 109 PFU/m2 was decreased to 5 x 109 PFU/m2/min (see Patients and Methods). At the slower administration rate, dosing reactions occurred infrequently in subsequent patients and were less severe. The symptoms of back pain, chest tightness, and hypertension were suggestive of a vasospasm effect, although no ECG changes were observed and prophylaxis with antihistamines was found to be ineffective. Tumor site–specific adverse events including inflammation. A separate class of adverse events dependent on the tumor location was noted. These tumor site–specific adverse events included the following:
Hematology/coagulation profiles. After the first dose of the first course of PV701, all patients experienced a transient drop in leukocyte and platelet counts with full recovery to baseline observed within 7 to 14 days, regardless of dose level. Clinically significant thrombocytopenia (Southwest Oncology Group grade 4, nadirs of 19,000 and 23,000 platelets/µL) and leukopenia (grade 4) were observed in two and three patients, respectively. However, these patients were carefully monitored clinically with follow-up hematology profiles performed 12 hours to 4 days later and a rapid recovery in blood counts was observed in all cases. No episodes of bleeding or infection resulted from these transient drops in counts. The pattern of thrombocytopenia and leukopenia was identical for patients who were given one dose as for those who were given up to six doses, indicating that this phenomenon was due to the first PV701 dose. The rate of recovery was the same for the single-dose patients as for those who were given multiple PV701 doses with full recovery noted by day 14 in all patients, including those who were given subsequent doses up to 10 times higher than dose 1. There were no significant changes in leukocyte and platelet counts during subsequent courses. There were no significant changes in hemoglobin or hematocrit values after PV701 dosing in patients without baseline anemia. Grade 3 anemia was reported for six patients, all of whom had significant anemia at baseline. Specific assays were added to the standard coagulation panel to serve as early predictors of potential disseminated intravascular coagulation (ie, fibrinogen and fibrin split products). There were no dose- or time-related changes in these parameters or in the standard coagulation parameters (prothrombin time, partial thromboplastin time) that were considered clinically significant and related to therapy. Hypoglycemia in patients on oral hypoglycemic agents or insulin. Three instances of clinically significant hypoglycemia occurred. All three patients had diabetes (two were receiving oral hypoglycemic agents, and one was receiving insulin). After the initial PV701 dose, these patients experienced nausea and dehydration, resulting in limited oral intake. Hypoglycemia was not observed after subsequent PV701 dosing. It is unknown whether PV701 administration also increased the bioavailability of the hypoglycemic therapy. Discontinuing these agents in the immediate postdosing period after dose 1 resulted in no additional episodes of hypoglycemia. Dose escalations, DLT, and determination of MTD. In the single-dose regimen, doses between cohorts were escalated in two-fold increments from 5.9 to 24 x 109 PFU/m2. As can be seen in Table 5, one adverse event (grade 4 diarrhea) that met the definition of DLT was seen in the first cohort (5.9 x 109 PFU/m2) of six patients. Severe diarrhea was not seen on subsequent higher dose levels when loperamide was given prophylactically at the first sign of gastrointestinal side effects. No DLTs were seen in six patients in the 12 x 109 PFU/m2 cohort. At the 24 x 109 PFU/m2 dose level, a DLT (grade 3 dyspnea) occurred in a patient with a lung tumor mass and baseline signs of pulmonary infiltrate. This patient also experienced grade 3 hypoglycemia. Dyspnea and hypoglycemia were not considered dose dependent in this trial because severe dyspnea was associated with patients having lung/pleural tumor masses and hypoglycemia only occurred in patients with diabetes (discussed in Hypoglycemia in Patients on Oral Hypoglycemic Agents or Insulin).
In the single-dose regimen, the only dose-dependent toxicity was grade 2 hypotension, which occurred in three of five patients in the 24 x 109 PFU/m2 cohort. Because the intention was to establish an outpatient dosing regimen, dose 1 was not escalated further. The dose of 12 x 109 PFU/m2 was therefore established as the outpatient MTD for the first dose with grade 2 hypotension as dose limiting. The repeat-dose regimen tested for the presence of any cumulative toxicity at two dose levels (5.9/5.9/5.9 and 12/12/12 x 109 PFU/m2) in a total of 13 patients. As indicated in Table 5, only a single DLT was observed (grade 3 dyspnea), which occurred in a breast cancer patient with baseline bilateral pleural effusions dosed at 5.9/5.9/5.9 x 109 PFU/m2, the lower of the two dose levels. No cumulative toxicity was seen. A dose of 12 x 109 PFU/m2 was therefore chosen as a first dose (or "desensitizing dose") for escalation of the second and subsequent doses in the desensitizing regimen. In the desensitizing regimen, one DLT was observed in the first four cohorts with a total of 24 patients (Table 5). This acute dosing reaction (grade 3 back pain) at 12/96/96 was attributed to the infusion rate (see Acute Dosing Reactions above), which was slowed for subsequent patients. In the 12/144/144 x 109 PFU/m2 cohort of 13 patients, three DLTs were observed and dose escalation was stopped. These events were seen after the 144 x 109 PFU/m2 dose: grade 3 tremors and dehydration in an 81-year-old woman, grade 3 dehydration in a 75-year-old man, and grade 3 hypoxia associated with 30 minutes of rigors in a man with lung cancer. For patients in the 2-week regimen, repeat doses lower than 144 x 109 PFU/m2 were therefore tested. There was no significant difference in adverse event profile or laboratory values for repeat doses of 96 or 120 x 109 PFU/m2 given five times over 2 weeks, no cumulative toxicity was seen, and patients tolerated equally well either of these doses. Therefore, the dose of 120 x 109 PFU/m2 was determined to be the second dose MTD.
Serious Adverse Events and Deaths Three patients with baseline bacterial infections were administered PV701 and had episodes of sepsis after PV701 therapy. Two patients had a baseline urinary tract infection. The other patient had baseline fever in the week before beginning PV701 treatment and had baseline bacteremia immediately before his first dose of PV701. There were five patient deaths, four of which were clearly attributed to progressive disease occurring during the 4-week reporting period. The remaining death occurred in a 55-year-old man with renal carcinoma metastatic to the lungs. At baseline, he had compromised pulmonary function as a result of previous lobectomies, lobar atelectasis, and an 8-cm metastasis in one of the two remaining lobes. In addition, he was status postradical nephrectomy with a 4-cm tumor metastasis in his remaining adrenal gland. This patient was enrolled in the 12/120 x 5 doses x 109 PFU/m2 dose level. After an initial (and only) PV701 dose of 12 x 109 PFU/m2, he experienced grade 3 hypotension that required intravenous hydration and 48 hours of hospitalization. Three days later, he was admitted to a local community hospital with complaints of fatigue, lethargy, and severe respiratory distress. Mechanical ventilation was advised but was declined. The patient died as a result of respiratory failure approximately 12 hours later. At autopsy, an enlarged subcarinal lymph node (5 x 4 x 3 cm) filled with partially hemorrhagic and necrotic tumor tissue was reported as well as a metastatic tumor that measured 8 x 7 x 6 cm just below the inferior pleural surface of the left upper pulmonary lobe. Histologic sections of the left lung were reported as showing the presence of localized thrombi only in the tumor vessels with tumor necrosis and severe edema/inflammation only in the tumor-bearing lung and mild to absent in the non–tumor-bearing lung. Inflammation was not reported in any other organ.
Response Assessment Of the 62 patients who were eligible for response assessment, 14 had freedom from tumor progression for 4 to 30+ months and two had radiographic evidence of major responses. A complete response was documented in a 51-year-old man with tonsillar (squamous cell) carcinoma. At the time of enrollment, this patient had disease progression during cisplatin and radiation therapy (with the most recent treatment given in September 1998) as noted by a radiographic increase during the preceding 3 months. After a baseline MRI scan in January 1999 (Fig 1A) demonstrating a 1.5-cm tumor in the pharynx, he received PV701 at the 12/96/96 x 109 PFU/m2 dose level. After one cycle, he achieved a radiographic complete response as evidenced by resolution of the tumor on MRI. Follow-up scans after months 2, 3, and 5 of therapy confirmed the radiographic complete response (Fig 1B). The patient was noncompliant and discontinued therapy between months 5 and 7. An MRI scan at month 7 indicated disease progression elsewhere in the pharynx (lateral oropharyngeal wall).
A partial response was documented in a 79-year-old-man who had colon carcinoma and had failed capecitabine, 5-FU, and irinotecan. He had not received any chemotherapy in the 2 months before his enrollment into the PV701 study at the 12/72/72 x 109 PFU/m2 dose level. At baseline, he had two liver metastases, the largest one well-circumscribed and measuring 10 cm in maximal dimension (Fig 2A). His CT scans at month 1 (Fig 2B) and month 2 after therapy showed overall tumor regression of greater than 70%. In addition, immediately after dosing there was a spike in carcinoembryonic antigen level (approximately 4.5-fold increase) followed by a drop to steady-state levels at 79% below baseline, shown elsewhere to be further indicative of a response.27 Progression-free survival of 10 months was observed in this patient. Seven other patients with diverse malignancies (including mesothelioma, melanoma, colon carcinoma, breast carcinoma, pancreatic carcinoma, and carcinoid) had measurable tumor reduction, although less than 50% of the total tumor burden.
Replacement of Tumor by Inflammatory Cells on Histologic Examination During the course of PV701 therapy, one patient had tumor tissue removed for electron microscopic examination and other tissue analysis. This 46-year-old man, who had bulky peritoneal mesothelioma that had progressed after debulking surgery and intraperitoneal doxorubicin/cisplatin and IFN-  , was enrolled at the 12/48/48 x 109 PFU/m2 dose level in January 1999. During 30 monthly courses of PV701, he has remained free from progression, has no disease-related symptoms, experienced an improvement in performance status (to Eastern Cooperative Oncology Group 0), gained muscle mass, and retained a high level of physical activity. CT scans performed on a monthly basis have shown up to a 35% reduction in bidimensional measurable disease (270 cm2 at study entry). Elective surgery to debulk disease 2 weeks after his last dose of the eighth course (in the eleventh month of PV701 administration) was unsuccessful. However, histologic examination showed a significant fraction of the tumor mass replaced by an active inflammatory process with edema in all sections of tumor (Fig 3A and 3B). This process consisted predominantly of plasma cells. Lymphoid follicles with germinal centers were also evident in the tumor, indicating an active immune reaction (Fig 3C). Electron microscopy revealed PV701 particles at tumor cell membranes (Fig 3D). The plasma cell infiltrate and secondary lymphoid follicles were not present in previous sections of tumor parenchyma taken before enrollment. A normal skin sample removed at the time of the patient’s tumor excision did not show any evidence of inflammation. His serum neutralizing antibody titer had reached a plateau level of 1:2,560 at the time of the tissue examination.
In another case, a different pattern of tumor inflammation was seen. Autopsy sections from a patient who had advanced pleural mesothelioma and died of progressive disease (tumor obstruction of the inferior vena cava) were reviewed. Lung metastases displayed a mononuclear inflammatory infiltrate mainly at the periphery of the larger metastases and throughout the smaller tumor masses (Fig 4A and 4B). Also observed in the lung metastases were signs of tumor necrosis, including multifocal areas at the tumor periphery (Fig 4A). The portion of lung without tumor was free of any signs of inflammation (Fig 4C). A similar pattern was seen in his liver metastasis (Fig 4D), which showed mononuclear inflammatory cells infiltrating the tumor but not uninvolved liver distal from the tumor (Fig 4E). A diffuse mononuclear inflammatory infiltrate was also seen in a mesenteric metastasis (Fig 4F) but not in the adjacent normal tissue. No such inflammatory process was present in the original biopsy of the primary tumor preceding PV701 treatment. Unlike the previous case of the patient with peritoneal mesothelioma, there was no sign of tumor regression in this particular patient and no samples of tumor tissue were obtained for viral analysis.
Among the various clinical tests of replication-competent viruses22-25,28,29 (Stojdl et al, manuscript submitted for publication), the phase I dose escalation study reported here is the first study in humans to determine an MTD for systemic (intravenous) administration. PV701, an oncolytic strain of Newcastle disease virus was studied because it demonstrated preclinical activity against a wide range of human tumors in vitro and in vivo and is active by the intravenous route. Importantly, Newcastle disease virus has previously been shown to lack pathogenicity in humans after low-dose administration3,8,20,21,30 mainly as a component of oncolysate tumor vaccines.8,20,21 This phase I study characterized the toxicity profile for intravenous PV701 dosing and demonstrated the feasibility and potential benefit of systemic (intravenous) oncolytic virus administration.
As expected from previously published reports on Newcastle disease virus serologic surveys,31,32 only one of the 32 patients tested was found to have neutralizing antibody before administration of the virus. After dosing with PV701, the majority (27 of 29) of patients tested developed varying levels of neutralizing antibody. Neutralizing antibody titers, even with multiple courses, reached a moderate plateau level of Low levels of viral shedding were observed and found generally to be transient. Recovery of virus from sputum was rare, was of low level, occurred only after the first cycle of virus administration, and always cleared within a maximum of 14 days. Recovery of virus from urine after the first cycle of PV701 was more common but again did not persist, being cleared within 3 weeks. Transient viruria was observed less frequently after subsequent cycles but did occur despite the presence of neutralizing antibodies. Ultimately, the incidence of transient viruria diminished to zero among patients who received PV701 for seven or more cycles. Relative to the environmental impact of shedding on the most susceptible host species (chickens), the observed levels of PV701 shedding are orders of magnitude below the standard avian vaccine dose required for an antibody response.33,34 The low and transient viral shedding seen in this study may be part of the explanation for the lack of any observed human-to-human transmission seen with PV701. This finding is in agreement with data from other clinical trials using Newcastle disease virus3 and with other human experience with the virus.3,6
The acute toxicity of PV701 principally consisted of flu-like symptoms (fever, chills, fatigue, headache, nausea, vomiting, and diarrhea) and dose-dependent hypotension that occurred 4 to 24 hours after PV701 dosing. Older patients ( Just as tachyphylaxis develops in mammals, including humans, with repeat IFN and TNF dosing,40-42 a striking reduction in the incidence and severity of PV701-mediated acute toxicity on repeat dosing was observed (Table 4). This phenomenon, termed "desensitization," was first observed with PV701 in the rodent models and applies to effects on toxicity but not efficacy. In preclinical testing using human tumor xenografts in athymic mice, efficacy increased with repeat dosing and toxicity was markedly reduced. After intravenous administration of 3 x 108 PFU, mice tolerated subsequent intravenous doses of 1 x 1010 PFU, indicating at least a 10-fold increase in the MTD.2 As fully predicted by these preclinical studies, this desensitization phenomenon allowed a 10-fold increase in the MTD observed in this trial with a first dose MTD of 12 x 109 PFU/m2 and a second dose MTD of 120 x 109 PFU/m2. The reduction in adverse event profile seen with the second PV701 dose compared with the first dose paralleled the reduction in serum cytokine levels seen after second PV701 dose, suggesting a causative role of proinflammatory cytokines in the clinical toxicity of PV701. As seen preclinically in both immunodeficient and immunocompetent mice, this desensitization phenomenon in patients does not depend on the development of antibodies to PV701 because it is seen as early as 2 days after the first PV701 dose (when antibodies are not detectable).
Desensitization also occurred with respect to transient drops in platelet and WBC counts. IFN and TNF- There was no observed cumulative toxicity associated with prolonged repeated PV701 dosing including a total of 116 repeat courses given to a total of 39 patients. One patient has had more than 30 courses of PV701 with no evidence of an adverse effect on any organ system. Because of desensitization and the lack of cumulative toxicity, an overall dose intensification of more than 100-fold was achieved in this trial (Table 1). Tumor site–specific inflammatory reactions were also seen. In this study, two patients with palpable tumors (colon cancer with a scalp metastasis and tongue cancer) developed inflammation and edema localized to the tumor sites. Histologic confirmation of tumor site–specific inflammation was obtained from representative patients. In one patient with metastatic pleural mesothelioma, tumor necrosis and a mononuclear cell inflam-matory infiltrate were observed only at tumor sites without any involvement of normal tissue, including tissue adjacent to disease sites (Fig 4). Evidence of such tumor inflammation as seen in this trial raises a question about the determination of responses by traditional imaging criteria, especially in future phase II trials. Tumor site–specific effects were also observed in patients with tumor involvement of the lung and liver. Oxygen desaturation, for example, was observed only in patients with pulmonary/pleural-based tumors (13 of 55 with involvement v zero of 24 without; P < .01). Significant elevation in liver enzymes was also limited, occurring only in patients with liver metastases (18 of 38 v zero of 41; P < .01). In addition, there was no evidence of generalized hepatocyte toxicity because total serum protein and clotting times remained comparable to baseline. Furthermore, the typical pattern of liver enzymes (elevated gamma glutamyl-transferase and alkaline phosphatase disproportionate to transaminases; and AST > ALT) was indicative of pressure on the canaliculi and cholangioles from a space-occupying effect rather than hepatocellular damage from hepatitis.48,49 Of cautionary note for future trials, patients with malignancy extensively replacing normal lung tissue, particularly if baseline pulmonary dysfunction exists, seem to be at risk for severe pulmonary toxicity. One such patient with preexisting compromised lung function died of respiratory failure. Severe edema and inflammation was found localized to the tumor-bearing lung along with thrombosis confined to the tumor vessels. Response assessment was not the focus of this phase I study, especially because, in this dose escalation study, most patients received low, potentially suboptimal dose intensities (Table 1). However, 62 patients were assessable. Evidence of efficacy included progression-free survival from 4 to more than 30 months in 14 patients who had clear evidence of disease progression before initiation of PV701. Furthermore, two radiographic objective responses (complete response and partial response) were documented and seven other patients had measurable tumor reductions, although not to the degree of a partial response. A 46-year-old man with advanced peritoneal mesothelioma unresponsive to intraperitoneal chemotherapy, with bulky disease (four 8- to 10-cm masses with total bidimensional measurable disease of 270 cm2) at baseline, has received more than 30 courses of PV701, has maintained an improved performance status (Eastern Cooperative Oncology Group 0), has had a radiographic minor response (of 35% tumor regression), and has experienced no cumulative toxicity. Evidence of a direct oncolytic effect of PV701 in this patient was found on biopsy after 11 months of PV701 administration. PV701 particles were observed budding from tumor cell membranes, and the tumor mass was extensively filled with mononuclear inflammatory cells (especially plasma cells) replacing tumor, indicating that PV701 had gained access to the tumor and was replicating there despite the presence of serum neutralizing antibody. In comparison to this patient with one of the largest tumor burdens enrolled onto the study, the patient with the smallest tumor burden (1.5 cm, tonsillar cancer) experienced a complete radiographic response after three doses of PV701. Collectively, these observations support the concept that systemic therapy with the replication-competent virus PV701 can provide a novel and potentially important therapy for patients with solid tumors, including those unresponsive to standard therapy. Moreover, long-term intravenous virus therapy seems to be feasible in humans and may play an important role in the treatment of solid tumors. Additional clinical studies of PV701 have begun.
Supported by Pro-Virus, Inc, Gaithersburg, MD, through Clinical Trial Agreements. We thank the dedicated nurses for patient care and study coordination. Phoebe L. Stewart, PhD, UCLA School of Medicine, is gratefully acknowledged for independent review of the electron micrographs. We thank John Bell, PhD, for permission to cite his unpublished review article on oncolytic viruses.
Presented in part at the Thirty-Seventh Annual Meeting of the American Society of Clinical Oncology, San Francisco, CA, May 12-15, 2001.
1. Roberts S, Buasen PT, Incao BA, et al: PV701, a naturally attenuated strain of Newcastle disease virus, has a broad spectrum of oncolytic activity against human tumor xenografts. Proc Am Assoc Cancer Res 42: 454, 2001 (abstr 2441) 2. Lorence RM, Roberts S, Groene WS, et al: Regression of human tumor xenografts following intravenous treatment using PV701, a naturally attenuated oncolytic strain of Newcastle disease virus. Proc Am Assoc Cancer Res 42: 454, 2001 (abstr 2442) 3. Lorence RM, Roberts MS, Groene WS, et al: Replication-competent, oncolytic Newcastle disease virus for cancer therapy, in Hernaiz Driever P, Rabkin SD (eds): Replication-Competent Viruses for Cancer Therapy, Monographs in Virology (vol. 22). Basel, Switzerland, Karger, 2001, pp 160-182
4.
Nelson NJ: Scientific interest in Newcastle disease virus is reviving. J Natl Cancer Inst 91: 1708-1710, 1999 5. Kleiman MB: Newcastle disease virus, in Lennette EH (ed): Laboratory Diagnosis of Viral Infections. New York, NY, Marcel Dekker, 1992, pp 567-571 6. Alexander DJ: Newcastle disease and other avian paramyxoviruses. Rev Sci Tech 9: 443-462, 2000 7. Reichard KW, Lorence RM, Cascino CJ, et al: Newcastle disease virus selectively kills human cancer cells. J Surg Res: 52: 448-453, 1992[CrossRef][Medline] 8. Schirrmacher V, Ahlert T, Probstle T, et al: Immunization with virus-modified tumor cells. Semin Oncol 25: 677-696, 1998[Medline] 9. Termeer CC, Schirrmacher V, Brocher EB, et al: Newcastle disease virus infection induces B7-1/B7-2-independent T-cell costimulatory activity in human melanoma cells. Cancer Gene Ther 7: 316-323, 2000[CrossRef][Medline] 10. Schirrmacher V, Bai L, Umansky V, et al: Newcastle disease virus activates macrophages for anti-tumor activity. Int J Oncol 16: 363-373, 2000[Medline] 11. Reichard KW, Lorence RM, Cascino CJ, et al: Selective replication of Newcastle disease virus in cancer cells is associated with virus-induced cell fusion. Proc Am Assoc Cancer Res 33: 521, 1992 (abstr) 12. Roberts MS, Lorence RM, Groene WS, et al: Treatment of neoplasms with viruses. International Patent Publication No. WO 99/18799, 1999 13. Stojdl DF, Lichty B, Knowles S, et al: Exploiting tumor-specific defects in the interferon pathway with a previously unknown oncolytic virus. Nat Med 6: 821-825, 2000[CrossRef][Medline] 14. Jaramillo ML, Abraham N, Bell JC: The interferon system: A review with emphasis on the role of PKR in growth control. Cancer Invest 13: 327-338, 1995[Medline] 15. Stark GR, Kerr IM, Williams BR, et al: How cells respond to interferons. Ann Rev Biochem 67: 227-264, 1998[CrossRef][Medline] 16. Gil J, Esteban M: Induction of apoptosis by the dsRNA-dependent protein kinase (PKR): Mechanism of action. Apoptosis 5: 107-114, 2000[CrossRef][Medline]
17.
Lorence RM, Reichard KW, Katubig BB, et al: Complete regression of human neuroblastoma xenografts in athymic mice after local Newcastle disease virus therapy. J Natl Cancer Inst 86: 1228-1233, 1994
18.
Lorence RM, Katubig BB, Reichard KW, et al: Complete regression of human fibrosarcoma xenografts after local Newcastle disease virus therapy. Cancer Res 54: 6017-6021, 1994 19. Cassel WA, Garrett RE: Newcastle disease virus as an antineoplastic agent. Cancer 18: 863-868, 1965[CrossRef][Medline] 20. Cassel WA, Murray DR: Treatment of stage II malignant melanoma patients with Newcastle disease virus oncolysate. Nat Immun Cell Growth Regul 7: 351-352, 1988[Medline] 21. Batliwalla FM, Bateman BA, Serrano D, et al: A 15-year follow up of AJCC stage III malignant melanoma patients treated post-surgically with Newcastle disease virus (NDV) oncolysate and determination of alterations in the CD8 T cell repertoire. Mol Med 4: 783-794, 1998[Medline] 22. Khuri FR, Nemunaitis J, Ganly I, et al: A controlled trial of intratumoral ONYX-015, a selectively-replicating adenovirus, in combination with cisplatin and 5-fluorouracil in patients with recurrent head and neck cancer. Nat Med 6: 879-885, 2000[CrossRef][Medline] 23. Markert JM, Medlock MD, Rabkin SD, et al: Conditionally replicating herpes simplex virus mutant, G207 for the treatment of malignant glioma: Results of a phase I trial. Gene Ther 7: 867-874, 2000[CrossRef][Medline]
24.
Ganly I, Kirn D, Eckhardt SG, et al: A phase I study of Onyx-015, an E1B attenuated adenovirus, administered intratumorally to patients with recurrent head and neck cancer. Clin Cancer Res 6: 798-806, 2000 25. Nemunaitis J, Cunningham C, Buchanan A, et al: Intravenous infusion of a replication-selective adenovirus (ONYX-015) in cancer patients: Safety, feasibility and biological activity. Gene Ther 8: 746-759, 2001[CrossRef][Medline] 26. Hao D, Rowinsky EK, Smetzer LA, et al: A phase I and pharmacokinetic study of intravenous (IV) p53 gene therapy with RPR/INGN-201 in patients (pts) with advanced cancer. Proc Am Soc Clin Oncol 20: 262a, 2001 (abstr 1045) 27. Quayle JB: Tumour lysis as a factor affecting blood levels of CEA. Br J Cancer 46: 213-219, 1982[Medline] 28. Kirn D: Systemic administration of replication-selective adenoviruses. Eur J Cancer 37: S65, 2001 (suppl 3, abstr 105) 29. Cattaneo R (ed): Replicating vectors for gene therapy. Gene Ther 8:S1-S13, 2001 (suppl 1) 30. Merigan TC, DeClercq E, Finkelstein MS, et al: Clinical studies employing interferon inducers in man and animals. Ann N Y Acad Sci 173: 746-759, 1970[CrossRef] 31. Miller LT, Yates VJ: Reactions of human sera to avian adenoviruses and Newcastle disease virus. Avian Dis 15: 781-788, 1971[CrossRef][Medline] 32. Charan S, Mahajan VM, Agarwal LP: Newcastle disease virus antibodies in human sera. Indian J Med Res 73: 303-307, 1981[Medline] 33. Newcastle disease vaccine. United States Code of Federal Regulations. Title 9, Part 113, Section 329, 1999 34. Thorton DH: Quality control of vaccines, in Alexander DJ (ed): Newcastle Disease. Boston, MA, Kluwer Academic Publishers, 1988, pp 347-365 35. Raj NB, Cheung SC, Rosztoczy I, et al: Mouse genotype affects inducible expression of cytokine genes. J Immunol 148: 1934-1940, 1992[Abstract]
36.
Baron S, Buckler CE: Circulating interferon in mice after intravenous injection of virus. Science 141: 1061-1063, 1963 37. Brehm G, Kirchner H: Analysis of the interferons induced in mice in vivo and in macrophages in vitro by Newcastle disease virus and by polyinosinic-polycytidylic acid. J Interferon Res 6: 21-28, 1986[Medline] 38. Busam KJ, Bauer TM, Bauer J, et al: Interleukin-6 release by rat liver macrophages. J Hepatol 11: 367-373, 1990[CrossRef][Medline]
39.
Lorence RM, Rood PA, Kelley KW: Newcastle disease virus as an antineoplastic agent: Induction of tumor necrosis factor- 40. Savage PD, Muss HB: Renal cell cancer, in DeVita VT, Hellman S, Rosenberg SA (eds): Biologic Therapy of Cancer ( ed 2 ). Philadelphia, PA, JB Lippincott, 1995, pp 373-387
41.
Fraker DL, Stovroff MC, Merino MJ, et al: Tolerance to tumor necrosis factor in rats and the relationship to endotoxin tolerance and toxicity. J Exp Med 168: 95-105, 1988 42. Fraker DL, Pass HI, Alexander HR, et al: Biologic therapy with TNF: Systemic administration and isolation-perfusion, in DeVita VT, Hellman S, Rosenberg SA (eds): Biologic Therapy of Cancer ( ed 2 ). Philadelphia, PA, JB Lippincott, 1995, pp 329-345
43.
Chapman PB, Lester TJ, Casper ES, et al: Clinical pharmacology of recombinant human tumor necrosis factor in patients with advanced cancer. J Clin Oncol 5: 1942-1951, 1987
44.
Creagan ET, Ahmann DL, Green SJ, et al: Phase II study of recombinant leukocyte A interferon (rIFN- 45. Creaven PJ, Brenner DE, Cowens JW, et al: A phase I clinical trial of recombinant human tumor necrosis factor given daily for five days. Cancer Chemother Pharmacol 23: 186-191, 1989[Medline] 46. Feldman ER, Creagan ET, Schaid DJ, et al: Phase II trial of recombinant tumor necrosis factor in disseminated malignant melanoma. Am J Clin Oncol 15: 256-259, 1992[Medline] 47. Quesada JR, Talpaz M, Rios A, et al: Clinical toxicity of interferons in cancer patients: A review. J Clin Oncol 4: 234-243, 1986[Abstract] 48. Pincus MR, Schaffner JA: Assessment of liver function, in Henry JB (ed): Clinical Diagnosis and Management by Laboratory Methods ( ed 19 ). Philadelphia, PA, WB Saunders, 1996, pp 253-267 49. Pincus MR, Zimmerman HJ, Henry JB: Clinical enzymology, in Henry JB (ed): Clinical Diagnosis and Management by Laboratory Methods ( ed 19 ). Philadelphia, PA, WB Saunders, 1996, pp 268-295 Submitted August 6, 2001; accepted February 4, 2002.
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Copyright © 2002 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
1,000-fold below the amount that adversely affects normal cells.
and IFN-
