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Vol. 3, 409-417, March 1997 Clinical Cancer Research 409
Phase I Evaluation of Intravenous Recombinant Human Interleukin
12 in Patients with Advanced Malignancies1
Michael B. Atkins,2 Michael J Robertson,
Michael Gordon, Michael T. Lotze,
Michelle DeCoste, Jon S. DuBois, Jerome Ritz,
Alan B. Sandler, Howard D. Edington,
Pamela D. Garzone, James W. Mier,
Christine M. Canning, Linda Battiato,
Hideaki Tahara, and Matthew L. Sherman
Tupper Research Institute and the Division of Hematology/Oncology,Tufts-New England Medical Center, Boston, Massachusetts 021 1 1[M. B. A., J. S. D., J. W. M.]; Division of Hematologic Malignancies,Dana-Farber Cancer Institute, Boston, Massachusetts 021 15 [M. J. R.,J. R., C. M. C.]; Division of Hematology/Oncology, IndianaUniversity School of Medicine, Indianapolis, Indiana 46202 [M. 0.,A. B. S., L. B.]; Department of Surgical Oncology, Pittsburgh CancerInstitute, Pittsburgh, Pennsylvania 15261 [M. T. L., H. D. E., H. I.];
and Genetics Institute, Inc., Cambridge, Massachusetts 02140 [M. D.,P. D. 0., M. L. S.]
ABSTRACT
A Phase I dose escalation trial of i.v. administered recom-
binant human interleuldn 12 (rhIL-12) was performed to de-termine its toxicity, maximum tolerated dose (MTD), pharma-
cokinetics, and biological and potential antineoplastic effects.
Cohorts of four to six patients with advanced cancer, Karnof-
sky performance �70%, and normal organ function received
escalating doses (3-1009 ng/kg/day) of rhIL-12 (Genetics Insti.
tute, Inc.) by bolus i.v. injection once as an inpatient and then,
after a 2-week rest period, once daily for five days every 3weeks as an outpatient Therapy was withheld for grade 3toxicity (grade 4 hyperbilirubinemia or neutropenia), and dose
escalation was halted if three of six patients experienced adose-limiting toxicity (DLI). After establishment of the MTD,eight more patients were enrolled to further assess the safety,
pharmacokinefics, and immunobiology of this dose.Forty patients were enrolled, including 20 with renal can-
cer, 12 with melanoma, and 5 with colon cancer; 25 patients
had received prior systemic therapy. Common toxicities in-
cluded fever/chills, fatigue, nausea, vomiting, and headache.
Fever was first observed at the 3 ng/kg dose level, typically
Received 8/20/96; revised 1 1/21/96; accepted 12/2/96.The costs of publication of this article were defrayed in part by thepayment of page charges. This article must therefore be hereby markedadvertisement in accordance with 18 U.S.C. Section 1734 solely to
indicate this fact.I This work was supported in part by Grants MOl-RR-00054 and MOl-RR7SO from the Division of Research Resources, NIH, and a stipendfrom Genetics Institute, Inc.2 To whom requests for reprints should be addressed, at Division ofAdult Hematology/Oncology, Department of Medicine, New EnglandMedical Center, 750 Washington Street, Box 542, Boston, MA 021 1 1.Phone: (617) 636-6527; Fax: (617) 636-0342.
occurred 8-12 h after rhIL-12 administration, and was incom-pletely suppressed with nonsteroidal anti-inflammatory drugs.
Routine laboratory changes included anemia, neutropenia,
lymphopenia, hyperglycemia, thrombocytopenia, and hy-poalbuminemiL DLTs included oral stomatitis and liver func-lion test abnormalities, predominantly elevated transaminases,
which occurred in three offour patients at the 1000 ng/kg dose
leveL The 500 ngflg dose level was determined to be the MTh.This dose, administered by this schedule, was associated withasymptomatic hepatic function test abnormalities in three pa-tients and an onstudy death due to Closb*Iia perfringens sep-
ticemia but was otherwise well tolerated by the 14 patients
treated in the dose escalation and safety phases. The T,,� elim-
ination of rhIL-12 was CalCUlated to be 5.3-9.6 h. Biologicaleffects included dose-dependent increases in circulating IFN-�y,
which exhibited attenuation with subsequent cycles. Serum
neopterin rose in a reproducible fashion regardless of dose orcycle. Tumor necrosis factor a was not detected by ELISA.
One of 40 patients developed a low titer antibody to rhIL-12.
Lymphopenia was observed at all dose levels, with recovery
occurring within several days of completing treatment without
rebound lymphocytosis. There was one partial response (renalcell cancer) and one transient complete response (melanoma),both in previously untreated patients. Four additional patients
received all proposed treatment without disease progression.rhIL-12 administered according to this schedule is biologically
and clinically active at doses tolerable by most patients in anoutpatient setting. Nonetheless, additional Phase I studies ex-aniining different schedules and the mechanisms of the specificDLTs are indicated before proceeding to Phase II testing.
INTRODUCTION
IL-l23 is a heterodirnenc cytokine with potent immunoregu-
latory activity. It was initially given the names natural killer cell
stimulatory factor and cytotoxic lymphocyte maturation factor (1,
2) based on its stimulatory effects on these cytolytic lymphokine
populations. The cDNAs encoding the two IL-l2 subunits are
unrelated and encode for two distinct proteins having molecular
masses of approximately 35 and 40 kDa (3, 4). The p35 subunit is
distantly related to IL-6, granulocyte colony-stimulating factor, and
chicken myelomonocytic growth factor, and the p40 subunit is
related to the extracellular domain of the IL-6 receptor, as well as
to the ciliaiy neurotrophic growth factor receptor (5, 6).
In vitro studies have shown that monocytes appear to be the
major source of IL-l2 in activated PBMC suspensions (7). Al-
though EBV-transforrned B cells appear to produce IL-l2, signif-
3 The abbreviations used are: IL, interleukin; PBMC, peripheral bloodmononuclear cell; NK, natural killer; TNF, tumor necrosis factor; AST,aspartate aminotransferase; DLT, dose-limiting toxicity; MID, maxi-
414 Phase I Trial of iv. rhIL-l2 in Advanced Malignancies
x xxxxx
AST (SGOT)
xxxx x
A
-I
I-0C,Cl)
I-Cl)4
xxxxx400�
350�
300�
250�
200�
150�
100�
50#{149}
B
0 10 20 30 40 50 60 70 80
DAY
xxxxx
ANC
xxxxx xxxxx
10 20 30 40 50 60 70 80
13
12
11
10
DAY
Fig. 2 Serial AST (SGOT; A) and neutrophil (ANC; B) levels for four individual patients over the first 70 days of therapy at the 500 ng/kg dose level.x,rhIL-l2 administration (500 ng/kg).
aggressive preventative treatment will enable higher doses of
rhIL-l2 to be safely administered remains to be determined.
Other cytokines have been shown to be potent inducers of
TNF-a (19), but despite the ability of IL-12 to induce some TNF
in vitro and the appearance of some side effects potentially
attributable to TNF, no TNF was detectable in the plasma of
patients receiving rhIL- 12. Therefore, in contrast to mechanisms
for toxicity proposed for other cytokines, toxicities observed in
response to rhIL-l2 administration are unlikely to be related to
secondary TNF production.
IL- 12 was shown in preclinical studies to allow the con-
tinued proliferation of preactivated NK and T cells, to enhance
Fig. 3 Serial mean serum IFN--y levels for patients treated at the top three rhIL-l2 dose levels. �, 250 ng/kg; #{149}, 500 ng/kg; 0, 1000 ngfkg. x,
rhIL-12 administration.
MEAN NEOPTERIN
300
250
-J� 2000EC
z 150
wI-0.
0wz
50
0
100
DAY
Fig. 4 Serial mean serum neopterin levels for patients treated at the top three rhIL- 12 dose levels. E, 250 ng/kg; #{149}, 500 ng/kg; 0, 1000 ng/kg. x,rhIL-l2 administration.
x�0tx �
0 10 20 30 40 50 60 70 80 90
Clinical Cancer Research 415
cytotoxic activity of T cells and NK cells, and to induce T helper
1 cell and inhibit T helper 2 cell differentiation (20-22). Special
studies to determine potential effects of rhIL-l2 on TH cell
distribution were not performed and, therefore, must await fu-
416 Phase I Trial of iv. rhIL-l2 in Advanced Malignancies
Table 4 Mean pharmacokinetic parameter estimates in patients receiving rhIL-12 as single iv. dose on day I
All values are mean ± SD. Cm�x, maximum concentration; V�, the volume of distribution at steady state: T112�11,,, the terminal or elimination
half-life: CL, clearance: and AUC0_,�, area-under-concentration versus time curve extrapolated to infinity.
Dose (ng/kg)
.�1
E0)
0.
c.,J
0C0
(0
C
C0
C)
100000
10000
I 000
I 00
0 5 10 15
Time After Administration (hrs)
Fig. 5 Concentration versus time profiles of all patients receiving 500ng/kg IL-l2 as a single iv. dose on day I. . individual patients:-, mean of all patients.
warranted, and if this schedule is to be used, that doses in the
range of 500 ng/kg should be tolerated by most patients.
Of note, a Phase II trial of rhIL-l2 in metastatic renal cell
carcinoma using this schedule (without the test dose) at the 500
ng/kg dose level was initiated, but had to be closed because of
unexpected severe toxicity (38). Although the reason for the
severe toxicity in this Phase II trial is still being explored, initial
results indicate that the omission of the test dose was a major
contributing factor.4 The observation from this study that IFN-�y
levels progressively declined with each successive cycle of
rhIL-l 2 supports the contention that prior rhIL-l2 administra-
tion may in some way exert a protective effect against subse-
quent toxicity and that this effect may be sustained over at least
4 J_ P. Leonard, M. L. Sherman, 0. L. Fisher. L. J. Buchanan, 0. Larsen, M.B. Atkins, J. A. Sosman, J. P. Dutcher, N. J. Vogelzang, and J. L. Ryan,Effects of single-dose interleukin 12 (IL-12) on IL-l2-associated toxicityand interferon--y production. manuscript in preparation.
a 10-17-day interval. Ifthis hypothesis is confirmed in ongoing
preclinical and subsequent clinical testing, then this would have
a major impact on the design of future rhIL- I 2 studies. Because
of the severe toxicity associated with minor schedule changes,
additional Phase I studies are necessary to examine alternative
schedules and further evaluate the significance and mechanism
underlying this “desensitization effect.”
ACKNOWLEDGMENTS
We thank Kerry Kappler, R. N., M. S., N. P., Sandy Dunstan, R. N.,
Lynn Colicchio, R. N., Lisa O’Connor, R. N., and Donna Kinzler, R. N.,for nursing support; Deborah Rovner, Steven Chartier, and Dr. Beth
Harrison-Mann for data management; Christine Cameron, Dr. Zhiling
Yu, and Kyle McCarthy for laboratory assistance: and Jacqueline L.
Myers for assistance in preparing the manuscript.
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