Phase II trial of fludarabine phosphate (F-Ara-AMP) in patients with advanced head and neck cancer

A Phase II Study of Tumor-infiltrating Lymphocyte Therapy for Human Papillomavirus-associated Epithelial Cancers

PURPOSE

Cellular therapy is an emerging cancer treatment modality, but its application to epithelial cancers has been limited. This clinical trial evaluated tumor-infiltrating lymphocyte (TIL) therapy for the treatment of patients with metastatic human papillomavirus (HPV)-associated carcinomas.

PATIENTS AND METHODS

The trial was a phase II design with two cohorts, cervical cancers and noncervical cancers. Cell infusion was preceded by a lymphocyte-depleting conditioning regimen and followed by systemic high-dose aldesleukin.

RESULTS

Objective tumor responses occurred in 5 of 18 (28%) patients in the cervical cancer cohort and 2 of 11 (18%) patients in the noncervical cancer cohort. Two of the responses in cervical cancer were complete and are ongoing 67 and 53 months after treatment. Responses in the noncervical cancer cohort were in anal cancer and oropharyngeal cancer. The HPV reactivity of the infused T cells correlated with clinical response. Peripheral blood repopulation with HPV-reactive T cells also correlated with clinical response.

CONCLUSIONS

These findings support the concept that cellular therapy can mediate the regression of epithelial cancers, and they suggest the importance of predictive biomarkers and novel treatment platforms for more effective therapies.

Review : Purine nucleoside analogues: Fludarabine, pentostatin, and cladribine

Purpose. An introductory template for an extensive discussion of the pharmacology, pharmacokinetics, clinical use and adverse effects of the currently ap proved adenosine analogues: fludarabine, pentostatin, and cladribine is profiled. This is part one of a three-part series.

Data Sources. We reviewed the literature through a MEDLINE search from 1986 to 1996. Relevant articles cited in literature obtained by MEDLINE searching were also considered. We searched the following terms: fludarabine, cladribine, pentostatin, apoptosis and adenosine ana logues. The search was restricted to the English language. We have incorporated pricing information from our prac tice sites as well as the average wholesale price for the purpose of cost comparison.

Data Extraction. We have reviewed the current literature with regard to the chemistry, mechanisms of action and pharmacology, pharmacokinetics, clinical use, adverse effects, drug interactions, indications, formulation, dosage, administration, pharmaceutical issues and a cost comparison of the currently approved adenosine ana logues, fludarabine, pentostatin, and cladribine.

Data Synthesis. The adenosine analogues are struc turally similar agents used in the management of hemato logical malignancies. Fludarabine and cladribine exhibit significant activity in CLL (chronic lymphocytic leukemia) and NHL (non-Hodgkin's lymphoma) and pentostatin and cladribine are both active in the treatment of hairy cell leukemia. There are no comparative clinical trials between the agents and we have provided comparisons based on pharmacology, clinical experience, adverse effects and cost as well as reviewing the clinical use of these agents.

Conclusion. The adenosine analogues, fludarabine, pentostatin, and cladribine, represent an important ad vance in the treatment of indolent lymphoid malignancies. Although response rates for fludarabine and cladribine in chronic lymphocytic leukemia and for pentostatin and cladribine in hairy cell leuemia are improved over standard therapy, the true clinical impact of these agents has not yet been realized. Additional studies in larger populations of both previously treated and untreated patients, as well as comparative trials between the deoxyadenosine analogues themselves need to be carried out. Moreover, combination chemotherapy trials with deoxyadenosine analogues and other cytotoxic agents need to be performed to determine the efficacy and toxicity of these combinations in various lymphoid malignancies.

Fludarabine phosphate. A new anticancer drug with significant activity in patients with chronic lymphocytic leukemia and in patients with lymphoma

Fludarabine phosphate is a purine antimetabolite approved for use in the management of patients with chronic lymphocytic leukemia. Fludarabine works primarily by inhibiting DNA synthesis. The compound also possesses lymphocytotoxic activity with preferential activity toward T-lymphocytes. Initial preclinical studies demonstrated antitumor activity with fludarabine against L1210 murine leukemia. In phase I studies, myelosuppression was identified as the dose-limiting toxicity in patients with solid tumors and fatal neurotoxicity as the dose-limiting toxicity in adult patients with acute hematologic malignancies. The recommended dose and schedule was determined to be 18-25 mg/m2/d for five days, repeated every 28 days. Unlike preclinical studies, phase II trials showed a lack of significant effect when fludarabine was given to patients with solid tumors. However, phase II investigations have confirmed the efficacy of fludarabine in lymphoid malignancies, including non-Hodgkin's lymphoma, mycosis fungoides, prolymphocytic leukemia, and chronic lymphocytic leukemia. The place of fludarabine in the management of leukemias in children is under investigation. Early results indicate an unusual degree of antitumor activity when the agent is used in combination chemotherapy for patients with refractory disease. Fludarabine is an effective antitumor agent in the management of lymphoid malignancies. Studies are ongoing to more completely define the role of fludarabine in these malignancies as well as in the pediatric leukemias. Additional studies evaluating the activity of fludarabine as an immunomodulator are warranted, due to the lymphocytotoxic properties associated with this agent.

Immunosuppressive effects and clinical response of fludarabine in refractory chronic lymphocytic leukemia

BACKGROUND

Fludarabine monophosphate is a new adenine nucleoside analogue with a promising efficacy in B-cell chronic lymphocytic leukemia (B-CLL) with response rates, including hematological complete remissions, of 50%-60% in previously treated and 75%-80% in previously untreated patients.

PATIENTS AND METHODS

Here, the clinical experience with and side effects of fludarabine are reported in 19 patients with refractory CLL (17 B-CLL, 2 T-CLL). All patients were pretreated with one to four different regimens and had progressive disease. Fludarabine was administered at a dosage of 25 mg/m2 daily for 5 days as a 30-minute intravenous infusion. This course was repeated every fifth week. Dosage and time course were adapted to toxicity.

RESULTS

12/18 (67%) evaluable patients achieved partial remissions (PR), 1/18 (6%) had stable disease (SD) and 5/18 (28%) were progressive. The median duration of partial remission until relapse or death was 6 months. Most responses to fludarabine occurred within two treatment courses. Major toxic effects included infections in 11 patients and nausea in 8 (mainly grade 1). Meanwhile, three patients died of progressive disease and 8 of pneumonias or other infections. Two patients had pneumocystis carinii pneumonias and one an aspergillus pneumonia. The high infection rate may be due not only to hypogammaglobulinaemia or fludarabine-induced granulocytopenia but also to a remarkable decrease of CD4(+)-cells during fludarabine therapy. In one case a tumor lysis syndrome was observed. No CNS toxicity was noted.

CONCLUSION

It is concluded that fludarabine is effective even in patients with advanced chronic lymphocytic leukemia refractory to multiple chemotherapy regimens. However, fludarabine has a remarkable suppressive effect on T-lymphocytes, predominantly CD4(+)-lymphocytes. Long-term antibiotic prophylaxis is recommended.