Originally published as JCO Early Release 10.1200/JCO.2005.03.4801 on March 6 2006

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Phase I Study of Antisense Oligonucleotide Against Vascular Endothelial Growth Factor: Decrease in Plasma Vascular Endothelial Growth Factor With Potential Clinical Efficacy

Alexandra M. Levine, Anil Tulpule, David I. Quinn, Gerardo Gorospe, III, D. Lynne Smith, Laurie Hornor, William D. Boswell, Byron M. Espina, Susan G. Groshen, Rizwan Masood, Parkash S. Gill

From the Departments of Medicine, Pathology, and Preventive Medicine, University of Southern California (USC), Keck School of Medicine, Los Angeles, CA

Address reprint requests to Alexandra M. Levine, MD, USC/Norris Comprehensive Cancer Center and Hospital, 1441 Eastlake Ave, Suite 3468, Los Angeles, CA 90033; e-mail: alevine{at}usc.edu

	ABSTRACT

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PURPOSE: Vascular endothelial growth factor antisense (VEGF-AS) is an antisense oligonucleotide that targets VEGF, inhibiting angiogenesis and tumor cell proliferation. This study established the safety, biologic effects, and pharmacokinetics of VEGF-AS in 51 patients with advanced malignancies.

METHODS: VEGF-AS was administered as a 2-hour infusion daily for 5 consecutive days for only one cycle on the first four dose levels, and then administered daily for 5 days every other week for up to 4 months on subsequent levels. Pharmacokinetics, tumor response, and the effect on plasma VEGF levels were determined.

RESULTS: The maximum-tolerated dose was 200 mg/m². Dose-limiting toxicities included grade 4 fever, and pulmonary embolism in one patient each at 250 mg/m². Mild anemia, fever, fatigue, and gastrointestinal complaints were the most common adverse events. VEGF-AS t_1/2ß (beta-phase terminal half-life of drug concentration) was 2.25 hours (range, 1.97 to 2.95 hours). Mean plasma VEGF-A (P = .002) and VEGF-C (P = .01) levels decreased 24 hours postinfusion, with a trend towards greater decreases at higher dose levels. At the maximum-tolerated dose, five of six patients demonstrated reductions in plasma VEGF. Clinical responses included complete remission in one patient with AIDS-Kaposi's sarcoma, a mixed but dramatic response in one patient with cutaneous T-cell lymphoma, and prolongation of progression-free survival compared with that obtained on the immediate prior regimen in six patients (12%) with renal cell, bronchoalveolar, small cell lung, thyroid, and ovarian carcinomas, and chondrosarcoma, respectively.

CONCLUSION: VEGF-AS was well tolerated, with biologic effects and preliminary evidence of clinical efficacy.

	INTRODUCTION

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Angiogenesis is the process whereby new blood vessels sprout in response to local stimuli. 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 which is also required for vascular development.^4,5 Thus, loss of only one VEGF allele in knockout mice results in embryonic death.^4,5 Similarly, VEGF receptors are essential for blood vessel formation.^6,7 Increased expression of VEGF receptors in endothelial cells of tumor vasculature attests to the significance of VEGF in tumor angiogenesis.^8,9

Interactions between VEGF, its three known receptor tyrosine kinases (VEGFR-1/Flt-1, VEGFR-2/Flk-1/KDR, and neuropilin-1), and tumor endothelium may result in augmentation of angiogenesis through recruitment of paracrine circuits.¹⁰ In addition, during neoplastic transformation, tumor cells may acquire aberrant expression of VEGFR-2 with the ability to carry mitogenic VEGF signals to the nucleus, a function otherwise limited to endothelial cells.¹¹ This autocrine growth factor activity of VEGF, demonstrated in a wide variety of tumor types, may also contribute to metastatic potential and poor outcome.^12,13

We developed a 21-mer phosphothioate-linked antisense oligodeoxynucleotide (VEGF-AS or Veglin [VasGene Therapeutics Inc, Los Angeles, CA]) against VEGF, which targets the coding region of VEGF common to all isoforms. The VEGF-AS binds to mRNA, inducing RNAse-H activity, resulting in mRNA degradation. In addition, the target mRNA cannot be translated when bound to VEGF-AS, due to size constraints in the ribosome complex. The overall effect of VEGF-AS is the reduction of VEGF protein levels.¹⁴ The VEGF-AS was capable of inhibiting cell viability in tumor lines that expressed both VEGF and VEGFR (VEGFR),¹³ and was also shown to be active in mice implanted with various human tumor cell lines including ovarian, prostate, bladder, and pancreas carcinomas, melanoma, mesothelioma, and Kaposi's sarcoma (KS).^13-15 Subsequent preclinical development demonstrated safety in mouse and monkey models.¹⁶

We herein report results of a phase I dose-escalation study of VEGF-AS administered to 51 patients with advanced malignancy.

	METHODS

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Study Design
We sought to determine the dose-limiting toxicity (DLT) and maximum-tolerated dose (MTD) of VEGF-AS administered as an intravenous infusion over 2 hours daily for 5 days on one occasion only (in the first four dose levels), and then administered daily for 5 days every other week for as long as 4 months in the subsequent 10 dose levels. To be assessable for DLT, patients were required to complete the 28-day safety assessment. Unassessable patients were replaced. This phase I trial used the standard 3 + 3 design, in which three patients were enrolled at each new dose level.¹⁷ The MTD was the highest dose level in which no more than one experienced a DLT, with six patients treated. No dose escalations were permitted within patients; however, two patients were entered twice, on two dose levels (Patient 3 was entered on dose level 1, then subsequently as patient 19 on level 6. Patient 13 was entered on dose level 3 and subsequently as patient 17 on level 6). Demographic data are presented for the cohort of 49 patients, whereas toxicity data are presented for the full 51 patients.

Definition of DLT
DLT was defined as grade 2 thrombotic event; grade 2 neuropathy; grade 3 coagulopathy; grade 3 or 4 nonhematologic toxicity; grade 3 or 4 drug-related thrombocytopenia; and grade 4 drug-related other hematologic toxicity. DLT occurring during the first course was used to decide whether to expand, escalate, or terminate accrual to the next dose level.

VEGF-AS Characteristics
The 21-mer phosphothioate linked antisense oligodeoxynucleotide VEGF-AS (5'-TGG-CTT-GAA-GAT-GTA-CTC-GAT-3') is complementary to VEGF mRNA sequences 261 to 281 as previously described.^12-15 Good manufacturing practices grade VEGF-AS was manufactured by Avecia (Milford, MA) for VasGene Therapeutics. The 21-mer oligonucleotide was more than 95% pure by capillary gel electrophoresis and high-pressure liquid chromatography. The remainder were n – 1 and n – 2 products.

Treatment Dose Levels
Levels 1 to 4 were administered daily over two hours by intravenous infusion for a total of 5 consecutive days. Subsequent dose levels allowed additional treatment, every other week for a possible 40 doses (four cycles) over 112 days (Table 1).

Pharmacokinetic Analyses
Blood was collected in heparin at prestudy, 0 minutes, 5 minutes, 15 minutes, 30 minutes, 1 hour, 4 hours, and 24 hours after completion of VEGF-AS infusion. Plasma was separated and stored at –80°C until analysis. Oligonucleotide was extracted from plasma, analyzed by high-pressure liquid chromatography, and pharmacokinetic analysis performed as previously described.¹⁸

VEGF-A and VEGF-C Levels in Plasma
Blood was collected in EDTA at prestudy, 0 hour, 1 hour, and 24 hours after completion of VEGF-AS infusion on day 1; after infusions on day 5; and on days 8, 15, and 28 of each course. Plasma was separated, and stored at –80°C until analysis using ELISA kits (R & D Systems Inc, Minneapolis, MN).¹³

Definition of Response and Progression-Free Survival
For patients with solid tumors, the Response Evaluation Criteria In Solid Tumors (RECIST) criteria were employed for assessment of tumor response.¹⁹ Standard response criteria were used to evaluate hematologic malignancies, including lymphoma, leukemia, and KS.^20-22 All patients were evaluated in terms of disease parameters at baseline, week 4 of cycles one, two, and four, and at the off-study visit, repeating those studies that were abnormal at baseline. Progression-free survival (PFS), for both the immediate prior regimen and for VEGF-AS, was calculated from the time of treatment initiation to the time of first observation of tumor progression or relapse. PFS attained from the regimen employed immediately before VEGF-AS was determined by reviewing computed tomography scans, positron emission tomography scans, and/or x-rays obtained just before institution of that regimen, as well as the scans obtained at the time of progression, when the patient was taken off that treatment.

Statistical Analyses
Before analysis, plasma VEGF-A and VEGF-C levels, pretreatment, and post–VEGF-AS infusion were log transformed to render distributions compatible with the assumptions required for parametric analysis.^23,24 Means and 95% CI were calculated in the log scale and then transformed back, yielding geometric means and associated confidence intervals. Two-tailed paired t tests²³ were used to test for mean changes from baseline; simple linear regression²⁴ was used to test for a trend across dose levels.

	RESULTS

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Patients Accrued
A total of 49 patients were accrued, including two individuals who were treated twice, on two distinct dose levels, resulting in 51 dose registrations. Characteristics of these patients are presented in Table 2.

Toxicity
Toxicities considered as possibly, probably, or definitely due to the VEGF-AS are documented in Table 3. The MTD of VEGF-AS was 200 mg/m². At level 14 (250 mg/m²), there were two DLTs, including grade 4 fever (maximum 40.4°C) and rigors in one patient, and pulmonary embolism in a 42 year-old female with pleural mesothelioma. No other grade 4 toxicities were observed. Grade 3 toxicities included neutropenic fever in one patient, and anemia in four patients. Grade 1 and 2 toxicities included hypotension, fever, fatigue, constipation, gas, diarrhea, nausea, anemia, flushing on the hands or face, and hot flashes. Four patients were not assessable for DLT, because of disease progression before completion of the first 28 days; all four patients were replaced by other patients at the same dose level.

Serious adverse events that were not drug related included death due to progressive cancer in 11 patients, neutropenic fevers in two patients with pre-existing neutropenia due to marrow involvement; and hospitalizations due to grade 3 anemia in one patient; gastrointestinal bleed from tumor in one patient; leg fracture secondary to trauma in one patient; esophageal stricture in one patient; and seizures secondary to underlying malignancy in one patient.

Pharmacokinetics of VEGF-AS
Pharmacokinetic parameters of VEGF-AS for the dose range 15 to 250 mg/m² were as follows: the median C_max was 14.6 mg/L (range, 1.4 to 43.5 mg/L), the median AUC was 36.6 mg/L · h (range, 1.9 to 110.0 mg/L · h), and the median t_1/2ß was 2.3 hours (range, 2.0 to 3.0 hours).

Plasma VEGF-A Levels
The pretreatment mean VEGF-A level was 103.5 pg/mL (95% CI, 78.5 to 136.6). At 24 hours postinitial VEGF-AS infusion, the mean VEGF-A level was 68.8 pg/mL, (95% CI, 52.2 to 90.7 pg/mL), representing a 33.8% decrease (95% CI, –48.9% to –14.4%; paired t-test P = .002). VEGF-A declined by more than 25% from baseline in 25 (51.0%) of 49 patients at 24 hours postinfusion, was unchanged in 14 (28.6%) of 49 patients, and increased by more than 25% in 10 (20.4%) of 49 patients. Greater decreases in VEGF-A levels were seen at the higher dose levels of VEGF-AS, although the trend was not significant (P = .24, regression analysis for trend over doses). Nonetheless, at the MTD of VEGF-AS (200 mg/m²), five (83%) of six patients experienced a fall in plasma VEGF by 24 hours, and five of five patients demonstrated an additional reduction by day 5 (Fig 1A). Thus, the median baseline VEGF level in the six patients treated at the MTD was 213.2 pg/mL (range, 44.6 to 632.7 pg/mL), falling to a median of 79.2 pg/mL (range, 49.1 to 114.2 pg/mL) at day 1; and falling again to a median value of 52.5 pg/mL (range, 23.6 to 129.2 pg/mL) at day 5. The seven patients with renal cell carcinoma experienced a clear decline in plasma VEGF levels, with a median baseline value of 282.7 pg/mL (range, 109.1 to 685.6 pg/mL), falling to a median of 128.0 pg/mL (range, 38.2 to 420.0 pg/mL by day 1; Fig 1B), whereas the seven patients with lymphoma or leukemia also experienced a fall from a median of 108.9 pg/mL at baseline (range, 28.2 to 283.3 pg/mL) to 51.1 (range, 33.6 to 100.0 pg/mL at 24 hours (Fig 1C). Insufficient numbers of patients were available to decipher the ability of VEGF-AS to reduce VEGF levels within other tumor types. In terms of correlation between VEGF levels and clinical response to the VEGF-AS, among eight patients with some clinical response, the median decrease in VEGF-A levels at 24 hours was –6% (range, –80% to +188%), whereas at 5 days postinitial VEGF-AS infusion, the median change was –49% (range, –98% to +1,031%). A total of 63% experienced a fall in VEGF by –25% at day 5. In contrast, among the 43 patients without clinical response, the median VEGF level at 24 hours was –30% (range, –97% to + 446%), the median change at 5 days was –26% (range, –97% to +331%), and 40% experienced a more than 25% fall by day 5.

View larger version (15K): [in this window] [in a new window]   Fig 1. Vascular endothelial growth factor (VEGF) levels in plasma after VEGF antisense. VEGF at baseline (day 0), 24 hours after the first infusion (day 1), and after four doses (day 5) in (A) patients at the maximum-tolerated dose (200 mg/m2); (B) patients with renal cell carcinoma; and (C) patients with lymphoma or leukemia. Patient numbers and dose levels are shown in the keys.

Clinical Responses
A pathologically documented complete remission of AIDS-related KS was obtained in patient 1, treated at dose level 1 (15 mg/m²). He was 44 years old, had KS since 1996, and had been on a stable regimen of highly active antiretroviral therapy for 1 year before study entry. His CD4 cell count was 175/mm³, and the HIV viral load was nondetectable at less than 400 copies/mm³. He had previously received human chorionic gonadotropin,^25,26 IM 862,²⁷ liposomal doxorubicin (Doxil; Alza Pharmaceuticals, Palo Alto, CA), paclitaxel and docetaxel, with progressive disease. At study baseline, he had eight raised and six flat KS lesions, all of which had occurred since his last therapy. Baseline VEGF-A level was 17 pg/mL, falling to 5 pg/mL by day 5. The duration of complete remission after VEGF-AS was 4 months, after which cutaneous relapse of KS was documented.

A second patient with tumor-stage cutaneous T-cell lymphoma experienced a dramatic, although mixed response to VEGF-AS, administered at level 7 (74 mg/m²). His baseline VEGF-A level was 122 pg/mL, falling to 60 pg/mL by day 42. He experienced a 64% decrease of measurable disease after cycle one (Fig 2A), with normalization of the skin on [¹⁸F]fluorodeoxyglucose positron emission tomography scan (Fig 2B). The patient received local radiation therapy to pre-existing tumors on the buttock and lower left leg during cycle one, and missed a total of 15 of the planned 40 doses of VEGF-AS therapy (38%). On day 99 of therapy, during cycle four, he developed a new tumor on the leg, whereas his skin continued to improve. This patient had received local radiotherapy to tumors on the leg in the past without experiencing an abscopal or distant effect of the radiation in terms of improvement of his skin disease.

View larger version (67K): [in this window] [in a new window]   Fig 2. Cutaneous T-cell lymphoma. (A) Photographs of skin lesions on the days indicated; (B) positron emission tomography images taken on the days indicated. Arrows point to areas of increased uptake in skin, consistent with cutaneous lymphoma. Pre, before treatment.

	DISCUSSION

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We have demonstrated that use of an antisense oligonucleotide against VEGF (VEGF-AS, Veglin) is associated with minimal toxicity at the MTD of 200 mg/m², and is capable of inducing decreases in plasma levels of VEGF-A and VEGF-C within 24 hours of administration. At the MTD, five of six patients demonstrated significant reductions in plasma VEGF levels by 24 hours postinfusion, and all five patients experienced additional reductions through day 5. Furthermore, the drug was associated with an objective tumor response in one individual, a mixed response in a second patient, and prolongation in PFS in six additional patients, when compared with the documented PFS obtained from the immediate prior therapy. A total of 63% (five of eight) of these individuals with evidence of some clinical effect experienced a more than 25% fall in VEGF-A by day 5 post–VEGF-AS versus 40% of the nonresponders, with a median fall in VEGF level at day 5 of 49% in responders, whereas nonresponders had a median fall of 26%. Evidence of an antineoplastic effect was seen in a variety of tumor types, including KS, lymphoma, renal cell, bronchoalveolar, thyroid, fallopian tube papillary serous, chondrosarcoma, and small-cell lung cancer.

One of the most potent stimulants of angiogenesis is tissue hypoxia, which commonly occurs as tumors outgrow their capillary blood supply. The resulting hypoxia stimulates expression of hypoxia-induced factor 1-, which in turn stimulates the production of angiogenic factors,²⁸ the most potent of which is VEGF, the only one whose activity is restricted to vascular endothelium.^29,30 Downregulation of VEGF could result in stabilization of tumor growth, with prolongation of PFS, as was demonstrated in this trial.

In addition to their effects on tumor vasculature, VEGFRs have also been demonstrated on malignant cells of various tumor types, thus providing another potential mechanism for enhanced tumor cell growth, with VEGF signaling through autocrine pathways. VEGFR-2 expression, which gives a mitogenic signal to vasculature and is the major mediator of VEGF in target cells,³¹ has been documented in melanoma, ovarian carcinoma, KS, and other malignancies.¹³ Through inhibition of autocrine growth loops, VEGF-AS could decrease cell proliferation, as was demonstrated in several patients in this trial, who achieved objective tumor responses after use of the drug. Additional antitumor effects of VEGF blockade may also occur through inhibition of paracrine growth signals, as shown by the ability of VEGF to stimulate stromal cells to produce interleukin-6, which may itself stimulate tumor cell growth.¹⁰

VEGF-A and VEGF-C levels were statistically decreased within 24 hours after infusion of VEGF-AS, providing proof of the principle that the antisense did, in fact, specifically decrease these angiogenic proteins. In vitro, VEGF-AS has been shown to inhibit VEGF-A and to a lesser extent, VEGF-C and VEGF-D, presumably due to partial homology between them.^13,32,33 It is possible that the early indication of efficacy of this approach is related to the ability of VEGF-AS to downregulate several members of the VEGF family.

The DLTs of VEGF-AS were shown to be fever and pulmonary embolism, the latter of which occurred in one patient (2%). No other patient developed evidence of venous thrombotic events (VTEs). The risk of VTE appears to be lower than that described for other angiogenesis inhibitors,^34-36 and metastatic carcinoma is a known risk factor for development of VTE, even in the absence of angiogenesis inhibitors.³⁷ No patient developed evidence of symptomatic cardiac compromise. Serial assessments of cardiac ejection fraction revealed asymptomatic decreases over 10% in four individuals, only one of which fell to below the normal range. VEGF-AS was also associated with grade 4 fever in one patient, serving as a DLT for the drug. Other grade 1 and 2 toxicities included fever, hypotension, and various gastrointestinal symptoms. Grade 1 flushing of the hands or face was also noted in 10% of patients, while sensations of a hot flash occurred in 14% of patients. Anemia (grade 2 or 3) occurred in 18% of patients, all of whom had been heavily pretreated for malignant disease.

The current study was limited by its phase I design, such that full information regarding the efficacy of this compound, or the optimal schedule or method of drug delivery have not yet been ascertained. Nonetheless, the use of VEGF-AS has been shown to be feasible, and associated with minimal toxicity at the MTD. Evidence of both biologic effects (fall in plasma VEGF levels) and clinical efficacy were most notable at the higher dose levels, suggesting a dose response relationship. Additional phase II studies are underway, in patients with renal cell carcinoma and KS, as well as a phase I study using VEGF-AS as a daily subcutaneous injection for up to 6 months.

	Authors' Disclosures of Potential Conflicts of Interest

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Although all authors completed the disclosure declaration, the following authors or their immediate family members indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.

Authors Employment Leadership Consultant Stock Honoraria Research Funds Testimony Other Lynne Smith VasGene Therapeutics (A) Rizwan Masood VasGene Therapeutics (A) Parkash S. Gill VasGene Therapeutics (C) VasGene Therapeutics (C) VasGene Therapeutics (A)

Dollar Amount Codes (A) < $10,000 (B) $10,000-99,999 (C) $100,000 (N/R) Not Required

	Author Contributions

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Conception and design: Alexandra M. Levine, Byron M. Espina, Susan G. Groshen, Parkash S. Gill Administrative support: Alexandra M. Levine, Lynne Smith, Laurie Hornor, Byron M. Espina Provision of study materials or patients: Alexandra M. Levine, Anil Tulpule, David I. Quinn Collection and assembly of data: Alexandra M. Levine, Anil Tulpule, Gerardo L. Gorospe III, Lynne Smith, Laurie Hornor, Byron M. Espina, Rizwan Masood, William D. Boswell Data analysis and interpretation: Alexandra M. Levine, Lynne Smith, Susan G. Groshen, Rizwan Masood Manuscript writing: Alexandra M. Levine, Lynne Smith, Susan G. Groshen, Parkash S. Gill Final approval of manuscript: Alexandra M. Levine, Parkash S. Gill Other: Gerardo L. Gorospe III, William D. Boswell

 

	GLOSSARY

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Abscopal: A reaction produced following irradiation but occurring outside the zone of actual radiation absorption.

Capillary gel electrophoresis: A method for separating biopolymers (eg, DNA and polypeptides) in a capillary filled with a network of cross-linked or entangled linear polymers (sieving matrix) with an applied electric field.

Chondrosarcoma: A malignant tumor arising from cartilage tissue.

KPS (Karnofsky performance score): A KPS (100 to 0) is used to evaluate a patient's therapeutic progress. A lower score predicts a lower chance of survival.

MUGA scan (multi-gated acquisition/angiogram): A noninvasive heart function test that uses a radioactive tracer to delineate the chambers of the heart and major vessels.

Neutropenic fever: An oral temperature of at least 100.4°F for at least 1 hour when the absolute neutrophil count is 0.5 x 10⁹/L.

Phosphothioate-linked antisense oligonucleotide: Phosphothioate is the substitution of one oxygen atom with sulfur in the internucleotide linkage. The phosphothioate modification renders the oligonucleotide more resistant to nuclease degradation without adversely affecting hybridization to complementary sequences.

Thrombocytopenia: Reduced platelet count.

	ACKNOWLEDGMENTS

 
We thank Paul Ketteridge of VasGene Therapeutics Inc for supplying VEGF-AS for this trial, and Marita Salvosa for monitoring of the clinical trial.

	NOTES

 
Supported by in part by VasGene Therapeutics Inc, an L.K. Whittier Foundation grant to the USC/Norris Comprehensive Cancer Center and Hospital, Concern Foundation for Cancer Research, The Ezralow Family Foundation, and research Grant No. 1R01 CA 79218 from National Institutes of Health and the National Cancer Institute (Bethesda, MD).

Presented in part at the 45th Annual Meeting of the American Society of Hematology, San Diego, CA, December 5-9, 2003; the 40th Annual Meeting of the American Society of Clinical Oncology, New Orleans, LA, June 5-8, 2004; and the 29th Congress of the European Society of Medical Oncology, Vienna, Austria, October 29-November 2, 2004.

Terms in blue are defined in the glossary, found at the end of this article and online at www.jco.org.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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Submitted July 26, 2005; accepted December 22, 2005.

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