Progression-free survival in 13 patients undergoing perioperative INGN 201 therapy and chemoradiotherapy. The estimated 1-year progression-free survival was 92%.
Overall survival in 13 patients undergoing perioperative INGN 201 therapy and chemoradiotherapy. The estimated 1-year overall survival was 100%.
Yoo GH, Moon J, LeBlanc M, Lonardo F, Urba S, Kim H, Hanna E, Tsue T, Valentino J, Ensley J, Wolf G. A Phase 2 Trial of Surgery With Perioperative INGN 201 (Ad5CMV-p53) Gene Therapy Followed by Chemoradiotherapy for Advanced, Resectable Squamous Cell Carcinoma of the Oral Cavity, Oropharynx, Hypopharynx, and LarynxReport of the Southwest Oncology Group. Arch Otolaryngol Head Neck Surg. 2009;135(9):869-874. doi:10.1001/archoto.2009.122
To assess the feasibility of treating patients with high-risk stage III and IV squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, and larynx with perioperative adenovirus-p53 (INGN 201) gene therapy along with surgery and chemoradiotherapy.
Design and Setting
A phase 2 study in a multi-institutional setting within the Southwest Oncology Group.
Thirteen individuals who met the following entry criteria: newly diagnosed, previously untreated squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx; selected stage III or IV disease without distant metastases; and surgically resectable disease.
Surgery, perioperative INGN 201 gene therapy, and postoperative chemoradiotherapy.
Main Outcome Measures
Overall patient status, tumor status, adverse effects, accrual rate, and percentage of patients successfully receiving the required doses of INGN 201.
All 13 patients received surgery and perioperative INGN 201 injections in the primary tumor bed and the ipsilateral neck. In addition, 3 patients received injections in the contralateral neck. Three patients did not receive chemoradiotherapy. One patient had a grade 2 fistula of the oral cavity. Of the 10 patients with evaluable data, 2 experienced grade 4 adverse events, 1 owing to hypokalemia, hyponatremia, vomiting, leukopenia, and neutropenia and 1 owing to increased aspartate aminotransferase and alanine aminotransferase levels. Seven other patients experienced grade 3 adverse events. The estimate of 1-year progression-free survival is 92%.
This trial demonstrated the feasibility of handling and delivering a very complex gene vector safely in multiple cooperative group institutions without significant incident. Intraoperative INGN 201 gene therapy is technically feasible, but it has many logistical problems when performed in a multi-institutional setting. Regulatory requirements might have hindered accrual in this multi-institutional setting. Disease control seems to be promising; however, no definitive conclusion can be made with this small sample size.
clinicaltrials.gov Identifier: locator="http://clinicaltrials.gov/ct2/results?term=NCT00017173" NCT00017173
In patients with advanced squamous cell carcinoma of the head and neck (SCCHN), 5-year survival is less than 40%.1 Current treatment options (surgery, radiotherapy, and chemotherapy) are toxic and functionally and cosmetically debilitating. The most common cause of death in patients with advanced SCCHN is locoregional recurrence.1 After surgery to remove gross disease, locoregional failure occurs because of microscopic cancer cells left in the margins of resection or in the neck. Adjuvant radiotherapy and chemotherapy have been added to treatment regimens in an attempt to kill these microscopic cancer cells. However, 25% to 40% recurrence exists.1 Because patients with advanced SCCHN have a high rate of locoregional recurrence and a low survival rate with the existing treatment modalities, novel biological therapies, such as gene therapy, are needed. Gene therapy may provide an alternative mechanism for controlling the microscopic residual disease with limited or no added toxic effects.
The p53 gene (NCBIEntrezGene 397276) is a tumor suppressor gene that is mutated in 45% of human cancers.2 In SCCHN, genetic alterations, such as p53 mutations, have been identified in histologically normal margins and have been correlated with a higher recurrence rate.3 The feasibility and efficacy of adenovirus-p53 (INGN 201 [Introgen Therapeutics, Inc, Houston, Texas]) intrawound therapy as an adjuvant to surgical resection was demonstrated in a mouse model that simulated residual microscopic disease after gross tumor resection of SCC.4 In the single-center phase 1 trial, a cohort of 15 patients with recurrent or refractory (failed multiple modalities of therapy) cancer who were eligible for palliative surgical resection were enrolled.5 This perioperative approach was found to be safe and well tolerated, with no significant added wound complications. A trial, therefore, was designed to test the feasibility and tolerability of perioperative injections in the tumor bed after surgical resection of SCCHN in a multicenter phase 2 setting.
All of the patients were evaluated by the departments of head and neck surgery, radiation oncology, medical oncology, and dentistry. Eligibility criteria included newly diagnosed, previously untreated SCC of the oral cavity, oropharynx, hypopharynx, or larynx; selected stage III or IV disease with nodal metastasis and without distant metastases; surgically resectable disease; and a Zubrod performance status of 0 or 1. The patients had negative test results for human immunodeficiency virus 1 or 2, hepatitis B virus, and hepatitis C virus. Patients had adequate laboratory test values, were informed of the investigational nature of this study, and gave written informed consent. The study was approved by local institutional review boards and institutional biosafety committees (IBCs) and was conducted under the auspices of the Southwest Oncology Group.
The goal of surgery was to remove all gross tumor via margin-negative resection. Therefore, intraoperative frozen sections should not have invasive tumor present. All of the patients (with N1, N2, or N3 disease) underwent a neck dissection ipsilateral to the neck mass. The decision to perform a selective, comprehensive, or radical neck dissection was made by the surgeon. Surgical quality review was performed for this study.
The injection technique is relatively simple, and participating surgeons completed a training course. Perioperative INGN 201 injections were performed in the intraoperative and postoperative periods. One dose of INGN 201 was considered to be 2.5 × 1012 viral particles in a total volume of 10 mL. Two doses of INGN 201 were administered intraoperatively. One dose of INGN 201 was injected into the surgical resection bed (mucosal and deep margins). Forty percent of the volume (4 mL) was injected into the mucosal margin within 1 cm of the edge of the resection. Sixty percent of the volume (6 mL) was injected into the deep bed that consists of muscle and fascia. No direct injections were applied to vessels or nerves.
The second dose of INGN 201 was injected into the neck dissection defect. After the neck dissection was completed, a half dose of INGN 201 (5 mL) was injected into the deep soft-tissue bed of the cervical level, where clinically evident nodal metastasis had been located. No direct injections were applied to vessels or nerves. The other half dose (5 mL) was placed in the neck dissection bed and was allowed to sit in place for 10 minutes. If patients required bilateral neck dissections, 1 dose was administered to the left neck and a second dose was administered to the right neck.
One dose of INGN 201 was administered postoperatively. A half dose of INGN 201 (5 mL) was given 48 to 72 hours postoperatively via retrograde injection into each of 2 drainage catheters next to the mucosal suture line and neck dissection bed. The INGN 201 was allowed to sit in place for 2 hours. If drainage catheters were inadvertently removed before 48 hours, no dose of INGN 201 was given postoperatively. If there was only 1 catheter in place, the full dose was given in 1 drain catheter.
The chemoradiotherapy regimen was started within 56 days of surgery. Cisplatin, 100 mg/m2, was infused during a 90-minute period every 21 days for 3 cycles, concurrent with radiotherapy. The initial field was the total volume, which included the primary tumor, any enlarged lymph nodes, and all areas at risk for microscopic disease. Patients received radiotherapy (60 Gy in 30 fractions during a 6-week period, with or without a boost of 6 Gy in 3 fractions during a 3-day period to high-risk sites). During treatment, patients were examined at least weekly.
Once treatment ended, an evaluation was required at 9 weeks, then every 3 months for the first year, twice annually in years 2 and 3, and annually thereafter. The patient's overall status, tumor status, and adverse effects were recorded.
This study was designed to assess the feasibility of treating patients with stage III and IV SCC of the oral cavity or oropharynx with perioperative INGN 201 gene transfer and surgery followed by chemoradiotherapy. Feasibility was assessed primarily by means of the accrual rate and the percentage of patients successfully receiving the required doses of INGN 201. If the accrual goal could not be met within 2½ years, the study would be considered not feasible with respect to accrual, and early closure of the study would be considered. Success in delivering INGN 201 therapy to the primary site was defined as receiving 65% or more of the planned doses to the mucosal margin and deep bed and the number of retrograde injections. The study would be considered feasible with respect to delivery if the true rate of patients receiving successful treatment was 85% and would not be considered feasible if the true rate was 70% or less. Sixty eligible patients would be sufficient to estimate the 2-year local control rate and the 2-year progression-free survival rate to within ±13% (95% confidence interval [CI]) given complete follow-up. Any adverse event occurring with at least 5% probability was likely to be seen once (95% chance).
Between March 1, 2003, and July 1, 2006, 13 patients were registered to the study from 3 participating institutions (Table 1). The study was closed on July 1, 2006, owing to poor accrual. The anticipated total accrual goal of 60 patients at a rate of 30 per year was not met. As a result, we did not demonstrate that a perioperative gene therapy trial would be feasible with respect to accrual in a multi-institutional setting. The many regulatory requirements involved in getting the study open and approved in each of the individual institutions may have dampened the initial enthusiasm for this trial, which hindered accrual. Of the 12 institutions that initially demonstrated a commitment to the protocol, only 5 opened the protocol with institutional review board and IBC approval. Getting approval in a timely manner proved to be difficult. In 1 of the 7 institutions that did not open the protocol, the IBC took 5 years to review the protocol and in the end never approved it. This protocol was open at 5 sites; however, only 3 institutions accrued patients. One institution opened the trial 36 months after submitting the application.
All 13 patients received surgery and perioperative INGN 201 injections in the primary tumor bed and the ipsilateral neck. In addition, 3 patients received injections in the contralateral neck. The 95% CI for the percentage of patients who received successful treatment delivery was 75% to 100%. Thus, given the observed extreme success rate, even in this small sample size, the prespecified null hypothesis of 70% was rejected, and, based on that fact, one could conclude feasibility. Based on the study data, there is no evidence that INGN 201 is not technically feasible to administer in the perioperative setting. Two of 13 patients had more than 4 mL injected into the mucosal margins and less than 6 mL injected into the deep surgical resection bed. Three patients did not receive any chemoradiotherapy. Two patients decided to receive radiotherapy closer to home and withdrew from the protocol. One patient was found to be pathologically node negative after surgery, and the treating physicians determined that chemoradiotherapy was not indicated.
All 13 patients were assessed for wound-healing complications before chemoradiotherapy (Table 2). One patient experienced a grade 2 orocutaneous fistula, and 1 patient had a grade 2 wound infection with grade 1 incisional separation. Three patients did not receive any chemoradiotherapy and thus provided no evaluable data for adverse events related to chemoradiotherapy. Of the 10 patients with evaluable data, 2 experienced grade 4 adverse events, 1 owing to hypokalemia, hyponatremia, vomiting, leukopenia, and neutropenia and 1 owing to increased aspartate aminotransferase and alanine aminotransferase levels. Seven other patients experienced grade 3 adverse events. Adverse events related to study treatment are summarized in Table 3. No adverse events in health care personnel or families were reported.
Of the 13 patients, only 3 are known to have died. All 3 had observed relapses before death: 2 in the regional lymph node basins and 1 at the primary site. Estimated 1-year progression-free survival was excellent (92%; 95% CI, 64%-100%) (Figure 1), as was estimated 1-year overall survival (100%; 95% CI, 75%-100%) (Figure 2). However, these estimates should be interpreted with caution owing to the small sample size. Median follow-up of the 10 patients still alive was 30 months (range, 20-44 months).
The feasibility to handle and deliver a very complex gene vector safely in multiple cooperative group institutions without significant incident was shown in this trial. The complexity and cost of such a study in the early era of gene therapy in a hospital environment that does not perform gene therapy on a routine basis and in a cooperative group setting is promising. Although most gene studies are executed in contained units, this trial demonstrated that gene therapy can be safely completed hospital-wide, such as in the perioperative arena. This trial confirms that gene therapy can be performed not only in experimental hospitals, such as M. D. Anderson Cancer Center, but also in the mainstream hospital environment, in which there is limited experience in this new field of treatment.
Injection of adenovirus-p53 into the surgical tumor microenvironment immediately after surgical extirpation of tumor represents a novel and possibly effective strategy to reduce local recurrence. Approximately 33% to 45% of SCCHN tumor cells have an altered p53 gene and could be targets for such therapy.6 Genetic alterations, such as p53 mutations, in patients with SCCHN have been identified in histologically normal margins and have been correlated with a higher recurrence rate.3 After adenovirus-p53 (INGN 201) was injected into surgically resected tumor beds of mice, tumor control and survival rates were improved.4 Because overexpression of p53 in head and neck cancer cells has demonstrated tumor growth suppression using in vitro and in vivo models and mutated and nonmutated p53 human SCCHN cell lines,4 the p53 mutation status was not measured for these patients. Additional mechanisms of action for INGN 201 have been evoked, including Fas-mediated apoptosis and anti-angiogenesis effects.
The previous p53 gene therapy studies6- 9 have not examined treating newly diagnosed patients with intrawound injection in a multi-institutional setting. In a single-center phase 1 trial, a cohort of 15 patients with recurrent or refractory cancer (failed multiple modalities of therapy) who were eligible for palliative surgical resection were enrolled.6 The disease in these patients was resectable but was thought to be incurable. Preoperatively, injections into a patient's tumor were performed 6 times in a 2-week period. Patients underwent surgical resection and were given an intraoperative injection of INGN 201 in the resected tumor bed and in the neck dissection site. Three days later, their drainage catheters were injected (retrograde) with INGN 201. All of the patients had extensive surgery and required flaps for closure. The surgical complications (1 vascular anastomotic thrombosis and 1 delayed wound healing) were expected and were unlikely to have been caused by INGN 201 therapy. Fever (n = 6), injection site pain (n = 5), and flulike symptoms (n = 4) were the only complications observed in these patients. Otherwise, the procedure was believed to be safe and well tolerated. After long-term follow-up (18 months), 4 patients (27%) were still alive and free of disease.5
A phase 2 INGN 201 intratumoral injection multicenter trial enrolled patients with SCCHN that was heavily pretreated, recurrent, and unresectable.7 Twenty-five of 112 patients (22%) experienced antitumor activity (partial response + complete response + stable disease), with median survival of 10.2 months. Overall, 7 of 112 patients (6%) responded (partial + complete response), with median survival of 40.8 months. Two phase 2 monotherapy studies8,9 using 2 dosing schedules (days 1, 2, and 3 every 4 weeks or days 1, 3, 5, 8, 10, and 12 every 4 weeks) enrolled patients with recurrent SCCHN that was heavily pretreated, unresectable, and resistant to all therapies. The related adverse events were fever and chills (74%), injection site pain (45%), asthenia (13%), nausea (1%), and injection site bleeding (10%). Twelve related severe adverse effects were reported (fever [in 4 patients], tumor hemorrhage [in 3 patients], and chills, injection site pain, dehydration, Guillain-Barré syndrome, and infection [in 1 patient each]). No treatment-related deaths were reported.
The present trial was closed on July 1, 2006, owing to poor accrual. Routine e-mails and telephone calls were made to the investigators to try to improve accrual. Furthermore, accrual was discussed and encouraged at the Southwest Oncology Group–Head and Neck Surgical Subcommittee semiannual meetings. In the United States, only 2% to 4% of patients with cancer are enrolled in clinical trials.10 Previous studies10 reveal that physicians have not been considering patients for clinical trials owing to a lack of available protocols and poor performance status. Patients often decline to participate in clinical trials because of a desire for other treatment, distance from the cancer center, and insurance denial.10 This trial has the complexity of gene therapy–related regulatory hurdles, among them IBC approval. Seven institutions could not obtain IBC approval, and 1 institution took 3 years to obtain it. In this limited institutional trial, only 3 of the initial 12 institutions accrued patients onto this protocol. Five institutions had the protocol approved. Furthermore, the initial excitement with gene therapy may have been tempered by results reported in other trials outside the Southwest Oncology Group, including low tumor response rates11 and an unrelated perceived concern about potential gene therapy toxic effects with the recent reports of the death of a patient treated with gene therapy11 who developed leukemia.12
The IBC at each institution required routine educational in-service meetings for all personnel who would have potential contact with treated patients, including personnel in the operating room, postanesthesia care unit, intensive care units, and inpatient floor units. No pregnant nurses were allowed to come in contact with these patients. In some cases, patient flow had to be altered into preselected intensive care units and floor units. Additional training was required for personnel in the disposal of waste and spill management. Family education and its documentation were also mandatory.
In conclusion, intraoperative INGN 201 gene therapy is technically feasible, but it has many logistical problems when performed in a multi-institutional setting. Regulatory requirements might have hindered accrual in this multi-institutional setting. Disease control seems to be promising; however, no definitive conclusion can be made considering the small number of patients treated. This sentinel trial provides the foundation for further testing of multi-institutional perioperative gene therapy and for the safe handling of a complex gene vector.
Correspondence: George H. Yoo, MD, Department of Otolaryngology, Head and Neck Surgery, Wayne State University, University Health Center 5-E, 4201 St Antoine, Detroit, MI 48201.
Submitted for Publication: September 12, 2008; final revision received January 1, 2009; accepted March 2, 2009.
Author Contributions: Drs Yoo, Moon, Lonardo, Kim, Hanna, Tsue, Valentino, Ensley, and Wolf had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Yoo, Moon, LeBlanc, Urba, Kim, and Hanna. Acquisition of data: Moon, LeBlanc, Lonardo, Tsue, Valentino, and Wolf. Analysis and interpretation of data: Moon, LeBlanc, and Valentino. Drafting of the manuscript: Yoo, Moon, LeBlanc, and Kim. Critical revision of the manuscript for important intellectual content: Moon, Lonardo, Urba, Hanna, Tsue, Valentino, Ensley, and Wolf. Statistical analysis: Moon and LeBlanc. Obtained funding: Kim. Administrative, technical, and material support: LeBlanc, Valentino, Ensley, and Wolf. Study supervision: Yoo, Lonardo, and Valentino.
Financial Disclosure: None reported.
Funding/Support: This investigation was supported in part by Public Health Service Cooperative Agreement grants CA32102, CA38926, CA14028, CA12644, CA27057, CA46136, and CA105409 awarded by the National Cancer Institute, US Department of Health and Human Services; and by Introgen Therapeutics Inc.