A phase III placebo-controlled study in advanced head and neck cancer using intratumoural cisplatin/epinephrine gel

Liposomal Phenylephrine Nanoparticles Enhance the Antitumor Activity of Intratumoral Chemotherapy in a Preclinical Model of Melanoma

Intratumoral injection of anticancer agents has limited efficacy and is not routinely used for most cancers. In this study, we aimed to improve the efficacy of intratumoral chemotherapy using a novel approach comprising peri-tumoral injection of sustained-release liposomal nanoparticles containing phenylephrine, which is a potent vasoconstrictor. Using a preclinical model of melanoma, we have previously shown that systemically administered (intravenous) phenylephrine could transiently shunt blood flow to the tumor at the time of drug delivery, which in turn improved antitumor responses. This approach was called dynamic control of tumor-associated vessels. Herein, we used liposomal phenylephrine nanoparticles as a "local" dynamic control strategy for the B16 melanoma. Local dynamic control was shown to increase the retention and exposure time of tumors to intratumorally injected chemotherapy (melphalan). C57BL/6 mice bearing B16 tumors were treated with intratumoral melphalan and peri-tumoral injection of sustained-release liposomal phenylephrine nanoparticles (i.e., the local dynamic control protocol). These mice had statistically significantly improved antitumor responses compared to melphalan alone (p = 0.0011), whereby 58.3% obtained long-term complete clinical response. Our novel approach of local dynamic control demonstrated significantly enhanced antitumor efficacy and is the subject of future clinical trials being designed by our group.

A nanoengineered topical transmucosal cisplatin delivery system induces anti-tumor response in animal models and patients with oral cancer

Despite therapeutic advancements, oral cavity squamous cell carcinoma (OCSCC) remains a difficult disease to treat. Systemic platinum-based chemotherapy often leads to dose-limiting toxicity (DLT), affecting quality of life. PRV111 is a nanotechnology-based system for local delivery of cisplatin loaded chitosan particles, that penetrate tumor tissue and lymphatic channels while avoiding systemic circulation and toxicity. Here we evaluate PRV111 using animal models of oral cancer, followed by a clinical trial in patients with OCSCC. In vivo, PRV111 results in elevated cisplatin retention in tumors and negligible systemic levels, compared to the intravenous, intraperitoneal or intratumoral delivery. Furthermore, PRV111 produces robust anti-tumor responses in subcutaneous and orthotopic cancer models and results in complete regression of carcinogen-induced premalignant lesions. In a phase 1/2, open-label, single-arm trial (NCT03502148), primary endpoints of efficacy (≥30% tumor volume reduction) and safety (incidence of DLTs) of neoadjuvant PRV111 were reached, with 69% tumor reduction in ~7 days and over 87% response rate. Secondary endpoints (cisplatin biodistribution, loco-regional control, and technical success) were achieved. No DLTs or drug-related serious adverse events were reported. No locoregional recurrences were evident in 6 months. Integration of PRV111 with current standard of care may improve health outcomes and survival of patients with OCSCC.

Survival Benefit of Radiofrequency Ablation with Intratumoral Cisplatin Administration in a Rabbit VX2 Lung Tumor Model

PURPOSE

This study evaluated the survival benefit of a combination therapy with radiofrequency ablation (RFA) and intratumoral cisplatin (ITC) administration for lung tumors by using a rabbit VX2 tumor model.

MATERIALS AND METHODS

Experiments were approved by the institutional animal care committee. VX2 tumor suspension was injected into the lungs of Japanese white rabbits under CT guidance to create a lung tumor model. Thirty-two rabbits bearing a transplanted VX2 lung tumor were randomly assigned to four groups of eight: control (untreated); RFA alone; ITC alone; and RFA with ITC. All treatments were performed one week after tumor transplantation. Kaplan-Meier survival curves were compared by the log-rank test.

RESULTS

The median survival time was 24.5 days (range 17-33 days) in the control group, 40 days (30-80 days) in the RFA alone group, 31.0 days (24-80 days) in the ITC alone group, and not reached (53-80 days) in the RFA with ITC group. The median survival was significantly longer with the RFA/ITC combination compared to the control group (P < 0.001), RFA alone (P = 0.034), and ITC alone (P = 0.004). The survival time after RFA alone was also significantly longer than that of the control group (P < 0.001). There was no significant difference in tumor size or the rate of pneumothorax between each group.

CONCLUSION

RFA prolonged the survival of rabbits with lung VX2 tumors when combined with ITC.

Cisplatin-directed coordination-crosslinking nanogels with thermo/pH-sensitive triblock polymers: improvement on chemotherapic efficacy via sustained release and drug retention

To realize the sustained release and long-term intratumoural retention of water-soluble cisplatin, thermo/pH-sensitive cisplatin-directed coordination-crosslinking nanogels (Pt-PNA) were developed via the coordination bonds of Pt-carboxyl groups. As the coordination ratio (CR) of the Pt-carboxyl bonds increased from 5% to 35%, the sizes of the Pt-PNA nanogels decreased from 999 nm to 167 nm, and their zeta potentials increased from -35 mV to -13 mV. Only through a simple mixing of cisplatin and PNAs, the entrapment efficiencies (EEs) of the Pt-PNA nanogels reached near 100% (>90%), and the drug-loading amounts (DLs) of cisplatin could achieve up to 25.5 ± 0.1%. For water-soluble cisplatin, Pt-PNA nanogels exhibited a sustained release for as long as 5 days. The thermo/pH-sensitive sol-gel phase-transition behaviour of the Pt-PNA nanogels were investigated via inverting-vial and rheological methods. Platinum elemental analysis indicated that the Pt-PNA nanogels showed a much stronger ability of cisplatin retention in tumours than free cisplatin. The platinum content in a tumour treated by the Pt-PNA nanogels was far higher than that by free cisplatin: 200.7 ± 63.6 μg vs. 82.7 ± 26.8 μg at the 1st day, or 118.9 ± 35.2 μg vs. 18.5 ± 9.4 μg at the 14th day. The evaluation of the in vivo antitumour efficacy indicated that only after a single dose of Pt-PNA nanogels, the tumour volume continuously decreased to 0.73 ± 0.07 times that of the original tumour volume (OTV) for 14 days; however, it rapidly increased by 3.37 ± 0.82, 8.01 ± 0.53 and 9.25 ± 1.85 times that of the OTV with the same dose of free cisplatin, PNA, and NS, respectively. Some preliminary evaluations of the biocompatibility indicated that the toxic side effects of cisplatin could be greatly improved via cisplatin-directed coordination-crosslinking with PNA. As a result, Pt-PNA nanogels could likely become a promising versatile strategy for improving antitumour efficacy and reducing the toxicity and size effects of platinum-based drugs, and they could also be developed as promising nanomedicines for regional chemotherapy.

Intratumoral chemotherapy for lung cancer: re-challenge current targeted therapies

Strategies to enhance the already established doublet chemotherapy regimen for lung cancer have been investigated for more than 20 years. Initially, the concept was to administer chemotherapy drugs locally to the tumor site for efficient diffusion through passive transport within the tumor. Recent advances have enhanced the diffusion of pharmaceuticals through active transport by using pharmaceuticals designed to target the genome of tumors. In the present study, five patients with non-small cell lung cancer epidermal growth factor receptor (EGFR) negative stage IIIa–IV International Union Against Cancer 7 (UICC-7), and with Eastern Cooperative Oncology Group (ECOG) 2 scores were administered platinum-based doublet chemotherapy using combined intratumoral-regional and intravenous route of administration. Cisplatin analogues were injected at 0.5%–1% concentration within the tumor lesion and proven malignant lymph nodes according to pretreatment histological/cytological results and the concentration of systemic infusion was decreased to 70% of a standard protocol. This combined intravenous plus intratumoral-regional chemotherapy is used as a first line therapy on this short series of patients. To the best of our knowledge this is the first report of direct treatment of involved lymph nodes with cisplatin by endobronchial ultrasound drug delivery with a needle without any adverse effects. The initial overall survival and local response are suggestive of a better efficacy compared to established doublet cisplatin–based systemic chemotherapy in (higher) standard concentrations alone according to the UICC 7 database expected survival. An extensive search of the literature was performed to gather information of previously published literature of intratumoral chemo-drug administration and formulation for this treatment modality. Our study shows a favorable local response, more than a 50% reduction, for a massive tumor mass after administration of five sessions of intratumoral chemotherapy plus two cycles of low-dose intravenous chemotherapy according to our protocol. These encouraging results (even in very sick ECOG 2 patients with central obstructive non-small cell lung cancer having a worse prognosis and quality of life than a non-small cell lung cancer in ECOG 0 of the same tumor node metastasis [TNM]-stage without central obstruction) for a chemotherapy-only protocol that differs from conventional cisplatin-based doublet chemotherapy by the route, target site, and dose paves the way for broader applications of this technique. Finally, future perspectives of this treatment and pharmaceutical design for intratumoral administration are presented.

Fool's gold, lost treasures, and the randomized clinical trial

Background

Randomized controlled trials with a survival endpoint are the gold standard for clinical research, but have failed to achieve cures for most advanced malignancies. The high costs of randomized clinical trials slow progress (thereby causing avoidable loss of life) and increase health care costs.

Discussion

A malignancy may be caused by several different mutations. Therapies effective vs one mutation may be discarded due to lack of statistical significance across the entire population. Conversely, expensive large randomized trials may have sufficient statistical power to demonstrate benefit despite the therapy only working in subgroups. Non-cost-effective therapy is then applied to all patients (including subgroups it cannot help). Randomized trials comparing therapies with different mechanisms of action are misleading since they may conclude the therapies are “equivalent” despite benefitting different subpopulations, or may erroneously conclude that one therapy is superior simply because it targets a larger subpopulation. Furthermore, minor variances in patient selection may determine study outcome, a therapy may be discarded as ineffective despite substantial benefit in one subpopulation if harmful in another, randomized trials may more effectively detect therapies with minor benefit in most patients vs marked benefit in subpopulations, and randomized trials in unselected patients may erroneously conclude that “shot-gun” combinations are superior to single agents when sequential administration of personalized single agents might work better and spare patients treatment with drugs that cannot help them. We must identify predictive biomarkers early by comparing responding to progressing patients in phase I-II trials. Enriching randomized trials for biomarker-positive patients can markedly reduce required patient numbers and costs despite expensive screening for biomarker-positive patients. Available data support approval of new drugs without randomized trials if they yield single-agent sustained responses in patients refractory to standard therapies. Conversely, new approaches are needed to guide development of drug combinations since both standard phase II approaches and phase II-III randomized trials have a high risk of misleading.

Summary

Traditional randomized clinical trials approaches are often inefficient, wasteful, and unreliable. New clinical research paradigms are needed. The primary outcome of clinical research should be “Who (if anyone) benefits?” rather than “Does the overall group benefit?”

Pharmacological and other interventions for head and neck cancer pain: a systematic review

Objectives

Pain is a common complication in head and neck cancer. The aim of this paper is to evaluate the evidence from randomised control trials investigating pharmacological and non-pharmacological methods of pain management in head and neck cancer.

Material and Methods

Medline, Embase and the Cochrane library databases were searched. Squamous cell carcinomas of the head and neck excluding nasopharyngeal and salivary gland cancers were included. The limits were "human" and "randomised clinical trials". A quality assessment was carried out.

Results

13 studies were included with a total of 644 participants. The primary outcome for most of these papers was pain control post-treatment. Levels of bias varied between the studies. Majority (12 out of the 13 studies) reported intervention to be superior to the control or standard therapy in pain management. Only 46% of the studies were carried out on an intention to treat basis. Two studies reported high dropout rates, with one at 66%.

Conclusions

There is insufficient evidence from randomised clinical trials to suggest an optimal pharmacological intervention for head and neck cancer pain post-treatment. Further high quality randomised clinical trials should be conducted to develop an optimal management strategy for head and neck cancer pain.

Direct intratumoral chemotherapy with carboplatin and epinephrine in a recurrent cervical chordoma: case report

OBJECTIVE

Chordomas are rare primary bone tumors for which surgery is classically the first-line treatment. However, safe margins are often difficult to obtain, so that patients are at risk of local recurrence. Because radiation therapy and systemic chemotherapy show limited effectiveness, we report the use of direct intratumoral chemotherapy (IC) to treat recurrent chordoma.

CLINICAL PRESENTATION

A 46-year-old man presented with a recurrent cervical chordoma after surgery and radiation therapy. This recurrence manifested as C4-C5 spinal cord compression.

TECHNIQUE

Three 22-gauge needles were inserted at the upper, middle, and lower parts of the tumor and advanced under computed tomographic guidance while injecting local anesthetic. A 5-mg/mL carboplatin solution was combined with epinephrine (to increase the concentration and antitumor effect of carboplatin) at a final concentration of 0.01 mg/mL and an iodinated contrast agent. We injected 3 to 5 mL of this solution over 5 minutes through each needle under computed tomographic guidance. Eleven intratumoral treatments were performed during an 18-month period.

CONCLUSION

A marked clinical response with regression of the spinal cord compression was observed, without specific toxicity. A good partial response was obtained with a 42% decrease in tumor volume (from 69 to 40 cm3). Moreover, the central part of the tumor showed tumor necrosis, as confirmed by histological examination. Thus, in patients with this rare tumor, intratumoral chemotherapy may be a valid treatment option when surgery and radiation therapy fail. Furthermore, intratumoral chemotherapy in combination with surgical treatment should be considered to improve the local control rate.

US-guided interstitial chemotherapy using paclitaxel temperature-responsive gel for breast cancer treatment in rat

INTRODUCTION

This study aims to investigate the therapeutic effect of paclitaxel temperature-responsive gel (PTRG) for interstitial chemotherapy on breast cancer, and to explore a new minimally invasive treatment for breast cancer.

MATERIALS AND METHODS

Breast cancer models were induced in rats using subcutaneous transplantation of tumor cells. The rats were then divided into control, paclitaxel injection, gel injection and paclitaxel-gel (PG) group. Following treatment, all animals were checked regularly by ultrasonography to observe changes in the tumors. Biopsy tumor tissues were processed for histopathological examination, and apoptotic index was determined by the terminal deoxynucleotidyl transferase dUTP nick end labeling method. In addition, blood cell count and liver transaminase activity were monitored, and the survival time of rats with cancer recorded.

RESULTS

Rats in PG group exhibited liquefaction necrosis of tumors. Ninety days after the experiment, four rats exhibited complete extinction of tumors, indicating full recovery. Pathological examination revealed that the tumor tissues in these rats were mostly necrotic, and the apoptotic index of tumor cells increased markedly compared to PI group. Also, the red blood cell, hemoglobin and white blood cell levels declined significantly in the PI group compared with PG group, while glutamic-pyruvic transaminase and glutamic-oxalacetic transaminase activities significantly increased. Meanwhile, no toxicity due to treatment was observed in PG group.

CONCLUSION

Interstitial chemotherapy mediated by PTRG appeared to be a safe and effective treatment for breast cancer in rats. It might have clinical applications for treating human breast cancer.

Magnetisches Drug Targeting—ein neuer Ansatz in der lokoregionären Tumortherapie mit Chemotherapeutika

BACKGROUND

Advanced squamous cell carcinomas of the head and neck region were often treated with combined radio-chemotherapy. Radiotherapy allows a focused treatment of the tumor, and healthy tissue can be protected from radiation. Chemotherapy, however, is mostly given systemically and the unwanted negative side effects also develop in many other organs.

AIM OF THE STUDY

Locoregional application of chemotherapeutic agents with Magnetic Drug Targeting on an animal experimental study.

METHODS AND RESULTS

Magnetic Drug Targeting is a new approach to the locoregional treatment of tumors. Ferrofluids (colloidal dispersion of magnetic nanoparticles) were reversibly bound to chemotherapeutic agents and injected intra-arterially, while focused with an external magnetic field to a certain body compartment (i.e. the tumor). With only 20% or 50% percent of the regular systemic chemotherapeutic dose, we achieved an up to 26 times higher concentration in the tumor region with this application compared to the usual systemic administration.

CONCLUSION

Magnetic Drug Targeting offers an unique opportunity to treat tumors locoregionally with chemotherapeutic agents.

Selective High-Dose Intra-Arterial Cisplatin as Palliative Treatment for Incurable Head and Neck Cancer

OBJECTIVE

The purpose of the present study was to evaluate the palliative effect of selective intra-arterial chemotherapy in progressive unresectable head and neck cancer previously treated with radiochemotherapy.

PATIENTS AND METHODS

8 patients with advanced residual or recurrent squamous cell carcinoma of the head and neck were evaluated. These patients were included in the present study particularly because of progredient pain and recurrent bleedings due to tumor progression. In addition 6/8 patients suffered from unpleasant tumor-related smell. All patients received simultaneous infusions of cisplatin (150 mg/m2) intra-arterially to the tumor and sodium thiosulfate intravenously (9 g/m2) for systemic neutralization of cisplatin. The patients were treated by at most 4 cycles of selective intra-arterial chemotherapy via femoral approach.

RESULTS

Tumor-associated pain, occurrence of tumor bleeding and tumor-related smell were reduced after at least 2 cycles of intra-arterial chemotherapy in all patients. Clinical and radiological assessment of the primary tumor site revealed a partial response in 4 patients while 4 patients were classified as nonresponders. Intra-arterial cisplatin treatment was well tolerated.

CONCLUSION

Selective intra-arterial cisplatin therapy can be delivered safely for palliation of tumor-related symptoms of incurable head and neck cancer.

Assessing tumor-related signs and symptoms to support cancer drug approval

Cancer causes premature death and significant, often devastating, symptoms. While prolongation of survival is an obvious end point for new cancer drug approval, the US Food and Drug Administration (FDA) has also utilized end points that evaluate patient symptoms. In this article we discuss the end points, evidence, and analyses supporting cancer drug approvals based on evaluations of tumor-related signs and symptoms. With advice from the Oncologic Drug Advisory Committee (ODAC) in the late 1970s and early 1980s, FDA determined that acceptable end points for cancer drug approval were survival or an improvement in the quality of a patient's life, e.g., an improvement in tumor-related symptoms. This article summarizes 15 FDA cancer drug approvals based on patient symptom assessments and/or physical signs (thought to represent symptomatic improvement) as the primary evidence of effectiveness. These include painful bone events (three cases), cosmetic improvement in Kaposi's sarcoma and cutaneous T-cell lymphoma (six cases), the consequences (decreased transfusions, etc.) of long-duration responses in leukemias and lymphomas (two cases), relief of pulmonary or esophageal obstruction (two cases), and one case each of symptom benefit in pancreatic cancer (also associated with survival benefit) and pulmonary symptom benefit in lung cancer. An instructive example of an individual patient benefit end point is discussed, though it did not lead to a drug approval (the cisplatin-epinephrine gel application). Improved trial designs and analysis plans may allow greater reliance on morbidity assessments to support future cancer drug approvals. Drug sponsors are encouraged to include symptom assessments in cancer clinical trials and to perform further research to improve symptom-assessment methods. The FDA routinely meets with sponsors at End of Phase 2 Meetings to discuss drug development plans and the design of phase 3 trials. We encourage sponsors to request special protocol assessments (SPA) after meeting with the FDA to get written confirmation of the adequacy of plans for assessing cancer morbidity and quality of life, including protocols, end points, statistical analysis plans, and draft case report forms.