Co-administration of cG250 and IL-2 or IFN-.alpha. for treating cancer
such as renal cell carcinomas
United States Patent: 7,632,496
Issued: December 15, 2009
Inventors: Warnaar; Sven
Ole (Leiden, NL), Ullrich; Stefan (Starnberg, DE)
Assignee: Wilex AG (Munich,
Appl. No.: 10/517,338
Filed: June 23, 2003
PCT Filed: June 23, 2003
PCT No.: PCT/EP03/06591
371(c)(1),(2),(4) Date: December
PCT Pub. No.: WO2004/002526
PCT Pub. Date: January 08,
Web Seminars -- Pharm/Biotech/etc.
A method for enhancing the therapeutic
effect of cytokine treatment is disclosed. More specifically the present
invention relates to a method for administering to a tumor patient a
therapeutic dose of cytokine in combination with antibodies directed
against the tumor associated antigen carbonic anhydrase IX (CAIX/G250/MN).
The improved treatment method is characterized in a significantly reduced
cytokine-related toxicity combined with potentiated effectiveness of
anti-G250 antibody alone, resulting in a positive therapeutic response
with respect to that observed with single anti-tumor agents alone.
Description of the
The invention relates to a method for the
treatment of malignant disorders, particularly renal cell carcinoma (RCC),
comprising the coadministration of low-dose cytokine, particularly IL-2 or
IFN-.alpha., and an antitumor antibody.
It is estimated that 30,000 new cases of renal cell carcinoma (RCC) were
diagnosed in the United States in 1999, with 11,900 deaths resulting from
the disease (1). Estimates of new cases that have overt metastatic disease
at the time of diagnosis range from 25% to 40% (2;3). Prognosis for these
patients is bleak, with a median survival of 10 months. For the remaining
cases in which the disease appears to be localized, the treatment of
choice is radical nephrectomy. However, one third of these patients will
later manifest metastatic disease and ultimately die from their cancer.
To date chemotherapy has not demonstrated sufficient anti-tumor activity
to prolong the survival of patients with metastatic disease (4;5). Single
agent or multiple agent chemotherapy has not demonstrated a response rate
greater than 10-15%. Due to less than satisfactory responses to
chemotherapy and surgery, and to the indirect evidence that host immune
mechanisms play a significant role in the natural history of RCC, there is
a continued exploration of immunotherapy in this disease (6-8).
Interferon-alpha (IFN-.alpha.) and interleukin-2 (IL-2) have indeed shown
anti-tumor activity in approx. 20% of patients (9-13), but this was often
associated with severe toxicity.
Interleukin-2 (IL-2) is an immune system stimulating agent that can
enhance proliferation and activation of T cells, NK cells and LAK cells
and can induce the secretion of a variety of cytokines including IL-6 and
interferon alpha (IFN-.alpha.) and gamma (IFN-.gamma.). Initial
administration of IL-2 causes a transient disappearance of lymphocytes
from the vascular compartment with a rebound after 24-48 hrs. After
prolonged administration an expansion of various types of white blood
cells is seen. IL-2 has been extensively investigated as an immune
therapeutic for cancer and was shown to have activity against melanoma and
renal cancer (6,8). High dose IL-2 therapy has been approved by FDA for
the treatment of advanced renal cell carcinoma. The dosing scheme consists
of an intravenous bolus of 0.6-0.7 MIU/kg every 8 hrs, repeated until
further therapy is limited by toxicity (18). A treatment course consists
of two cycles of therapy separated by 7-10 days. In each cycle patients
may receive 10-14 doses of IL-2. The overall response rate is 15% with 5%
There is considerable toxicity related to this high dose IL-2 treatment,
requiring uptake in an intensive care unit. A sepsis-like syndrome with
hypotension requiring pressor support as well as a systemic vascular
leakage leading to respiratory distress can occur. Other toxicities/side
effects are cardiac arrhythmia, fluid retention, fever, headache and
mental confusion, elevation of liver enzymes, nausea and vomiting,
thrombocytopenia, hyper/hypothyreoidism, and pruritus (18). Due to the
high toxicity profile alternative dosing schemes have been developed, such
as low dose iv and sc treatment, aiming at reducing toxicity while
retaining efficacy. In general it can be stated that these low dose
treatments indeed are far less toxic (19-22). Generally, this low-dose
IL-2 treatments, however, do not show any substantial efficacy.
The antibody G250 recognizes the tumor-associated antigen carbonic
anhydrase IX (CAIX/G250/MN), present on more than 75% of renal cancers.
The reactivity with normal tissues is restricted to the gastric epithelium
and the biliary ducts in the liver (14;15). Phase I/II trial of the murine
G250 antibody with .sup.131I labeling for radioimmunotherapy has been
completed and the results have been published (16). A chimeric G250
antibody constructed from a mouse Fv region with a human IgG1 kappa Fc
region (15) has been shown to be equivalent to the murine G250 antibody in
competitive combinding assays. The chimeric antibody was labeled with
.sup.131I and used for diagnostic study in RCC patients (17).
The administration of a combination of cytokines and therapeutic
antibodies has been described (24, 25, 26, 27, 28; U.S. Pat. No. 5,104,652
and WO 01/87336. There have been different schemes for the administration
of antibody and cytokine combinations, which, however, have generally not
shown the desired synergic effects and finally remained unsuccessful. Most
of the IL-2 treatment protocols comprise an intermittent short-term
administration of IL-2 in order to reach a reduction of the side effects.
Liu et al.(Cancer Immunol Immunother 51 (2002), 171-177) describe a
cytokine enhancement of ADCC by administration of chimeric G250 antibody
in vitro. According to the authors, these results suggest that a
combination immunotherapy of chimeric G250 antibody with cytokines such as
IL-2 might show promise in the treatment of RCC.
An abstract of Beck et al., Proceedings of the American Association for
Cancer Research, Vol. 43, (Mar. 2002) describes a phase I/II trial with
monoclonal antibody G250 in combination with low dose IL-2 in metastatic
RCC. In phase I, patients received G250 once weekly i.v. and IL-2 s.c.
according to an alternating low dose and periodic pulsing treatment scheme
over 6 weeks (1.8 MIU or 5.4 MIU IL-2 per day, single dose). During phase
II, six patients continued to receive treatment for another 6 weeks and
nine additional patients were enrolled for a 12-week treatment. While the
treatment was tolerated well, 4 of 14 patients showed stabilization of
initially progressive disease. One of these four showed a partial
remission when seen for the follow up in week 34. An additional patient
had a partial remission first observed in week 16, this response was last
confirmed in week 34.
The object underlying the present invention was to provide a treatment
protocol for coadministering an anti-tumor antibody and a low dose
cytokine which is more efficient than previous protocols without causing
substantive side effects.
According to the present invention, a novel method for the treatment of a
malignant disorder is provided, comprising coadministering an anti-tumor
antibody and a cytokine, wherein the cytokine is administered continuously
or repeatedly, preferably daily in a low dose form.
A further embodiment of the present invention relates to a method for the
treatment of a malignant disorder, comprising:
a) first treatment stage comprising administering a low-dose cytokine,
preferably a continuous or repeated administration of a low-dose cytokine,
b) a second treatment stage comprising coadministering an anti-tumor
antibody and a low-dose cytokine, wherein the cytokine is preferably
administered continuously or repeatedly.
According to the present invention, the cytokine is administered in a
low-dose form, wherein the administration preferably occurs continuously
or repeatedly over the whole therapy interval. The administration is
preferably daily each second day, and/or three times a week. By means of
this continuous/repeated low-dose administration, the cytokine level is
sufficiently high to increase the activity of the anti-tumor antibody,
e.g. by increasing ADCC and/or to activate the immune system of the
patient, e.g. the NK cells without causing substantial side effects,
particularly cytokine-related toxicity. Compared to an administration of
the anti-tumor antibody or the cytokine alone, the therapeutic efficacy of
the combined administration is increased by more than 15%.
The administration of "low-dose cytokine" according to the present
invention means that the cytokine is administered in a dose which is
pharmaceutically effective in improving the efficacy of an antibody
therapy in the substantial absence of toxic side effects, e.g. in the
substantial absence of grade 3 or higher of National Cancer Institute
(NCI) Common Toxicity Criteria (CTC) Version 2.0, April 1999, more
preferably in the substantial absence of grade 2 or higher and most
preferably in the substantial absence of grade 1 or higher.
The cytokine is preferably selected from the group consisting of
interleukins, e.g. IL-2,3,4,5,6,7,8,9,10,11,12,13,14 and 15, interferons
e.g. IFN-.alpha., IFN-.beta. and IFN-.gamma., TNF-.alpha., TNF-.beta.,
nerve growth factor (NGF), ligands of CD 40, FAS, CD 27 and CD 30,
macrophage-inhibiting protein, Rantes, active fragments and
pharmaceutically acceptable analogues and derivatives thereof and mixtures
thereof. More preferably, the cytokine is selected from IL-2 and IFN-.alpha..
A preferred dosage of IL-2 in the range of 1 MIU to 10 MIU daily,
particularly in the range of 1.5 MIU to 6 MIU daily. The preferred dosage
of IFN-.alpha. is 1 to 10 MIU three times a week, particularly in the
range of 1 to 4 MIU three times a week.
The cytokine dose may be constant during the whole treatment.
Alternatively, the dose may be a variable dose, particularly in the second
treatment stage of a two-stage protocol, i.e. the dose may be altered
during the treatment between a first low dose and a second low dose,
wherein the second low dose may be up to five times higher than the first
low dose. For example, the first low dose may be given in the first week
of treatment, e.g. in the second treatment stage of a two-stage protocol,
and in the second week, the first and second dose are given alternatively.
In the third week, the administration is as in the first week, the fourth
week, the administration is as in the second week and so on.
The cytokine may be administered subcutaneously or intravenously or in any
combination thereof. The preferred administration is subcutaneously.
The second active ingredient of the therapy according to the present
invention is an anti-tumor antibody. The term "anti-tumor antibody"
according to the present invention relates to any antibody which has
efficacy against a malignant disorder, particularly renal cell carcinoma.
Preferably, the antitumor antibody is directed against a so-called tumor
antigen, i.e. an antigen, particularly a polypeptide or a carbohydrate
structure which is associated with a malignant disorder such as specified
More preferably the antitumor antibody is selected from antibodies
directed against the MN (G250) antigen. Antibodies against the MN antigen
are for example described in EP-B-O 637 336. Especially preferable, the
antitumor antibody is a chimeric or humanized G250 antibody or a fragment
thereof. These antibodies may be produced by methods as described in
PCT/EP/02/01282 and PCT/EP/02/01283.
The antitumor antibody is preferably administered intravenously, e.g. by
infusion or intravenous injection. The administration of the antitumor
antibody is preferably in intervals of from 5-20 days, e.g. in intervals
of about 1 week.
The whole treatment protocol of the invention preferably comprises time
interval of from 50-200 days. If the treatment comprises a two-stage
treatment, the first treatment stage preferably comprises 5-20 days, e.g.
about one week and the second treatment stage preferably comprises 5-200
days, e.g. about 70-120 days.
Furthermore, the invention should be explained by the following examples.
Clinical Trial Comprising Coadministration of Chimeric G250 Antibody
(cG250) and IL-2
1.1 Endpoint Criteria
Primary Endpoints Toxicity Objective tumor response
Secondary Endpoints ADCC HACA Time to progression Overall survival 1.2
A prospective, open label, single arm, non-randomized phase I/II
multicenter trial was carried out in patients with advanced renal cell
cancer. In the phase I part of the study the first 6 patients received
cG250 once weekly intravenously and IL-2 subcutaneously according to an
alternating low dose (daily) and periodic pulsing treatment scheme for 6
weeks. After it was shown that the drug-related toxicity was acceptable
according to defined criteria these 6 patients were treated for another 6
weeks for a total of 12 weeks and an additional 9 patients (start of the
phase II part) were enrolled for a 12 weeks treatment. Patients showing
objective response (CR, PR) or stable disease were offered an additional
treatment cycle of 6 weeks.
The data base closure for the final analysis of all parameters except for
time of progression was the evaluation at week 22 for all patients.
Further, the results of the long-term follow up for defining the time to
progression of the objective responders and the stable disease patients
1.3 Study Treatment, Dosage and Dosage Regimen/Administration
cG250 was administered according to the treatment schedule in Table 1 (see Original Patent).
Per dose 20 mg of the chimeric monoclonal antibody cG250 were given once a
week (plus or minus two days) by intravenous infusion in 50-100 ml of
normal saline for 11 consecutive weeks in total, preceded by a week of
IL-2 alone. The infusion was administered over a period of 30 minutes.
IL-2 was administered subcutaneously according to the treatment schedule
in Table 1. Subjects received or self-administered at home a single daily
injection of commercially available recombinant human IL-2 for 12
consecutive weeks. Starting in week 1, patients received a single dose of
1.8 MIU sc IL-2 daily. In week 2 on day 1 the same amount of IL-2 was
given preceded by cG250. The remaining days of week 2 patient received 1.8
MIU sc per day. In week 3 from day 1 to 3, patients received sc IL-2
pulsing with 5.4 MIU per day. On the remaining days IL-2 was given at 1.8
MIU. The IL-2 treatment of week 3 was repeated in week 5, 7, 9, and 11,
the scheme of week 2 in week 4, 6, 8, 10, and 12.
In general the IL-2 injections were made early in the morning by the
patient at home. Only on days of cG250 administration this injection was
delayed until the patient was in the outpatient clinic. On the day of G250
application patients received IL-2 (irrespective of dose) one hour after
the G250 therapy.
1.4 Test Schedule and Procedures/Study Flow Chart
The study procedures are described in detail in this section. A general
overview of the tests and procedures of this protocol is given in the
G250/IL-2 application scheme (Table 1).
Patients were closely monitored for safety reasons during the treatment
period by weekly controls of vital signs, assessment of toxicity,
Performance Status and laboratory tests, eg CBC, blood chemistry and
radiological tests, if necessary. All blood drawings were performed before
the administration of IL-2 and G250, respectively. The total volume of the
blood drawings per patient in 5 months were about 300 ml.
The investigations/evaluations that were performed are listed in the
following Table 1
-- see Original Patent.
1.5 Toxicity Classification
Allergic reactions: Patients were removed from study for any grade
.gtoreq.2 allergic toxicity according to NCI CTC toxicity scale.
Fever: Patients with >39.degree. C. fever (grade 2), but without allergic
symptoms on the day of scheduled cG250 infusion did not receive cG250
until fever had dropped below 38.degree. C. (grade 0). If fever did not
drop in 2 days, the cG250 infusion was cancelled and treatment was resumed
on the next scheduled G250 infusion date.
The sc injections of IL-2 were on days with fever >39.degree. C. The daily
IL-2 injections were cancelled until fever has dropped below 38.degree. C.
In case the use of 500 mg paracetamol did not decrease the temperature
below 38.degree. C., the injection was suspended until the temperature is
below 38.degree. C. again.
Pain, itching, erythema, swelling, inflammation, phlebitis and ulceration
at the site of injection was considered as "local site reaction" according
to the NCI CTC criteria; urticaria was diagnosed as part of "allergic
1.6 Assessment of Efficacy
1.6.1 Efficacy Parameters
The objective response of the tumor was the main parameter of efficacy.
The tumor evaluation was performed based on the WHO Tumor Evaluation
Guidelines with 1) minimum size requirements for measurable target lesions
and 2) tumor masses with clearly defined bi-dimensional measurements.
The tumor measurements for target lesions were performed with CT-scan or
MRI scan. For all indicator lesions the minimum size of the largest tumor
diameter was 1.0 cm.
All measurable lesions .gtoreq.1.0 cm up to a maximum of 5 lesions per
organ and 10 lesions in total, representative of all involved organs, were
identified as target lesions and recorded and measured at baseline.
1.6.2 Methods of Assessments (eg Tumor Response, Specific Tests)
The tumor assessment was based on contrast medium-enhanced spiral
computer-tomography (CT) or magnetic resonance imaging (MRI). The same
procedures were used throughout the study. All measurements were recorded
in metric notation, using a ruler or calipers. All baseline evaluations
were performed as closely as possible to the beginning of treatment and
not more than 4 weeks before the beginning of treatment.
Tumor responses were evaluated according to the WHO criteria as follows:
Complete response (CR): The disappearance of all known disease determined
by two evaluations not less than four weeks apart.
Partial response (PR): 50% or more decrease in the sum of products of
largest and perpendicular diameters of the lesions which have been
measured to determine the effect of therapy by two evaluations not less
than four weeks apart. In addition there can be no appearance of new
lesions or progression of any lesion.
No change (NC)=Stable disease (SD): A greater than 50% decrease in total
tumor size can not be established nor has a 25% increase in the size of
one or more measurable lesions been demonstrated.
Progressing disease (PD): a 25% or more increase in the size of one or
more measurable lesions, or the appearance of new lesions.
1.6.3 Timing of Tumor Evaluations
Tumor evaluations were performed before study entry, at week 16 and 22 and
for drop-outs at time of drop-out. The assessment in week 22 did serve to
confirm the radiologic result seen in week 16.
An effort was made to follow up all patients who are not progressing
during their courses of treatment by performing CTs every 3 months after
end of cG250 treatment. This served to assess the duration of the
objective response or stable disease.
1.6.4 ADCC Assay
The antibody-dependent cell-mediated cytotoxicity (ADCC) of isolated
peripheral-blood mononuclear cells (PBMC) from patients was analyzed using
a .sup.51Cr release assay, according to Lamers et al. (29). Target cells
were the SKRC MW1-cl4 (G250 antigen overexpressing RCC cell line).
Controls were SKRC PBJ-cl1 (G250 antigen negative RCC cell line) and P815
(positive control with anti-P815 serum). After incubation with G250 and
serial dilutions of PBMC of the patients the .sup.51Cr released by lysed
target cells was measured in the supernatant. The weighted mean of
specific lysis of target cells was calculated.
The study was based on a sequential enrollment of two groups of patients
with a maximum of 30 evaluable patients enrolled. After enrolling 15
patients (stage 1) the study was continued enrolling the second group of
At the maximum enrollment number of 30 patients the trial was powered at
81% to detect an objective response rate of 15% against an assumed
spontaneous response rate of 5%.
This trial design was chosen to minimize the expected enrollment of
patients under objective and spontaneous response rates while maximizing
the chances of early stopping at the interim analysis. The method of
calculation was the Sequential Probability Ratio Test modified according
to Wald (30, 31).
The study size was based on .alpha..ltoreq.0.05 and 1-.beta..ltoreq.0.80
to detect a difference between a spontaneous response rate of 5% versus an
underlying true response rate of 15%.
According to an internationally accepted definition (32), an objective
response or disease stabilization for approximately at least six months
after the disease being progressive at study entry is generally accepted
as a "clinical benefit".
In the present study, approximately 30% of patients exhibited an objective
response or a disease stabilization for 22 weeks or longer and therefore
the above treatment schedule represents a "clinical benefit" for the
treated patient group. A clinical benefit to such an extent has not been
observed for this very problematic patient group (metastatic RCC patients,
often in the terminal stage of the disease).
Further, the treatment is safe. The combination treatment of i.v.
adminstered cG250 and sc administered IL-2 was well tolerated. No serious
adverse events against cG250 were observed. Moderate adverse events
typical for IL-2 treatment (and in most cases tolerable due to the low
dose administration) and no allergic reactions and no human anti-chimeric
antibody (HACA) reactions were observed.
Claim 1 of 11 Claims
1. A method for the treatment of renal
cell cancer comprising co-administering an anti-tumor antibody directed
against the MN antigen, wherein said antitumor antibody is a chimeric or
humanized G250 antibody or an antigen binding fragment thereof and a
cytokine to a subject in need thereof, wherein the cytokine is IFN-.alpha.
and is administered continuously or repeatedly in a low-dose form, wherein
the low-dose cytokine comprises a dose which is pharmaceutically effective
in the absence of NIC CTC toxicity grade 3 or higher, and wherein said
G250 antibody or fragment thereof and said IFN-.alpha. are the only active
ingredients which are administered.
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