' 1996 Nature Publishing Group http://www.nature.com/naturemedicine
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`........................................................
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`
`Treatment of advanced
`solid tumors with
`immunotoxin LMB- 1:
`An antibody linked to
`Pseudomonas exotoxin
`
`LEE H. PAIt, ROBERT WrrrEs 2 , ANN SETSER2 ,
`MARK C. WILLINGHAM 3 & IRA PASTAN’
`
`’Laboratory of Molecular Biology and ’Medicine Branch,
`National Cancer Institute, National Institutes of Health,
`9000 Rockville Pike, Bethesda, Maryland 20892, USA
`’Department of Pathology and Laboratory Medicine, Medical University of
`South Carolina, Charleston, South Carolina 29425, USA
`
`Immunotoxin 1MB-1 is composed of monoclonal antibody
`B3 chemically linked to PE38, a genetically engineered form
`of Pseudomonas exotoxin. B3 recognizes a carbohydrate
`antigen (1e5 ) present on many human solid tumors’. I-MB-i
`has excellent antitumor activity in nude mice bearing 1e 5 -
`positive tumors’. We conducted a phase I study of 38
`patients with solid tumors who failed conventional therapy
`and whose tumors expressed the 1e 5 antigen. Objective
`antitumor activity was observed in 5 patients, 18 had stable
`disease, 15 progressed. A complete remission was observed
`in a patient with metastatic breast cancer to supraclavicular
`nodes. A greater than 75% tumor reduction and resolution
`of all clinical symptoms lasting for more than six months
`was observed in a colon cancer patient with extensive
`retroperitoneal and cervical metastasis. Three patients (two
`colon, one breast cancer) had minor responses. The
`maximum tolerated dose of LM13-1 is 75 rig/kg given
`intravenously three times every other day. The major
`toxicity is vascular leak syndrome manifested by
`hypoalbuminemia, fluid retention, hypotension and, in one
`case, pulmonary edema. Although immunotoxins have been
`evaluated in clinical studies for more than two decades, this
`Is the first report of antitumor activity in epithelial tumors.
`
`350 (cid:9)
`
`Immunotoxins are potent cell-killing agents composed of mono-
`clonal antibodies conjugated to protein toxins made by bacteria
`or plants. Pdcin, saporin, Diphtheria toxin and PseudomonaS EXO-
`toxin (PE) have been widely used for this purpose’.
`Immunotoxins have been shown to be active against lym-
`phomas", but trials targeting solid tumors have been
`unsuccessful and have been associated with severe toxicities in-
`duced by the lack of specificity of the antibody or by the toxin
`moiety". Since epithelial tumors make up more than 80% of all
`adult cancers and cures are rare once they have metastasized, the
`development of new therapeutic approaches for solid tumors is
`necessary.
`Our laboratory has focused on immunotoxins made with
`Pseudomonas exotoxin A (PR). It is a 66-kD protein and kills cells
`by adenosine 5-diphosphate (ADP) ribosylation and inactivation
`of elongation factor 2, which causes the arrest of protein synthe-
`sis and cell death. PR is composed of three major structural
`domains each with a different function’ ,’. Domain la is responsi-
`ble for cell recognition, domain II for translocation across the
`cell membrane, and domain Ill for the ADP-ribosylation activity
`of the toxin. The major toxic effect of PE and immunotoxins
`containing PR is liver necrosis, a process initiated by the binding
`of domain la to hepatocytes.
`To decrease this nonspecific toxicity, domain la (amino acids
`1-252) of PE was removed by recombinant DNA technology. The
`resulting molecule, PE40, was much less toxic to the liver’.
`Subsequent deletion of amino acids 365-384 resulted in an even
`smaller molecule, PE38, that also retains full ADP-ribosylation
`activity, and yet is 0.5% as toxic to mice as native PR (ref. 10). To
`facilitate chemical coupling to antibodies, a small peptide con-
`taining a lysine residue was placed at the amino end of PE38 to
`make Ly5PE38.
`The monoclonal antibody B3 (IgGI K) recognizes a carbohy-
`drate antigen in the Ley family that is abundant on the surface of
`many human solid tumors and is present on only a few normal
`tissues’. Because of its very high reactivity with cancers, mono-
`clonal antibody B3 was used to make the immunotoxin LMB-1
`(B3-I.ysPF.38) by chemically coupling monoclonal antibody B3
`to LysPE38. LMB-1 was tested on cell lines and found to he very
`cytotoxic to cancer cells expressing the Le y antigen. Subse-
`quently LMB-1 was found to produce complete regressions of
`human tumor xenografts growing in immunodeficient mice’.
`Because of its promising activity in preclinical models, we initi-
`ated a phase I trial of LMB-1 in cancer patients at the Medicine
`
`NATURE MEDICINE, VOLUME 2, NUMBER 3, MARCH 1996
`
`IMMUNOGEN 2308, pg. 1
`Phigenix v. Immunogen
`IPR2014-00676
`
`

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`' 1996 Nature Publishing Group http://www.nature.com/naturemedicine
`ARTICLES (cid:9)
`
`................................................
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`
`
`Table 1 Toxlcities
`
`LMB-1 (cid:9)
`(mg/kg) (cid:9)
`
`Vascular leak syndrome - grade (cid:9)
`0 (cid:9)
`1 (cid:9)
`2 (cid:9)
`3 (cid:9)
`
`4
`
`Patients (n)
`
`10
`15
`20
`25
`30
`45
`60
`75
`90
`100
`
`2
`1
`1
`
`2
`1
`
`4
`1
`2
`3
`3
`1
`2
`3
`1
`
`2
`
`3
`3
`
`2
`
`1 (cid:9)
`
`4
`3
`3
`6
`3
`3
`6
`6
`3
`1
`
`Total (%) (cid:9)
`
`7 (20) 19 (54) 8 (23) 2 (4) 1 (2) (cid:9)
`
`38
`
`Branch, National Cancer Institute, in July 1993.
`To date, 38 patients with advanced solid tumors have been
`treated (16 male, 22 female) with a mean age of 47 (range
`30-70). Of these, 26 patients had colorectal cancer, 8 breast can-
`cer, 1 cancer of the esophagus, I cancer of the stomach, I
`
`ovarian cancer and 1 cancer of the ampulla of Vater. Patients re-
`ceived doses ranging from 10 to 100 .tg/kg (10, 15, 20, 25, 30, 45,
`60, 75, 90 and 100 .tg/kg). Three to six patients were treated at
`each dose level. The starting dose was 100 fig/kg (1/30th of the
`dose lethal to 10% of the mice tested (LD 0 )). This was subse-
`quently reduced to 10 .tg/kg because of grade 4 toxicity observed
`in one patient.
`The major side effect of LMB-1 was found to be vascular leak
`syndrome (VLS), manifested by hypoalbuminemia, fluid reten-
`tion and peripheral edema. At doses higher than
`75 .tg/kg,
`transient postural hypotension and scanty urination (oliguria)
`that did not require fluids or pressor agents were observed in
`some patients. Pulmonary edema and severe hypotension oc-
`curred in one patient who received 100 1g/kg. The severity of the
`VLS and the number of patients treated at each dose level are
`shown in Table 1. Other less frequent and well-tolerated side ef-
`fects include "finlike" symptoms, fever, malaise, skin rash,
`headache and nonspecific EKG changes. All drug-related side ef-
`fects occurred during the week of therapy and resolved within
`two weeks. Although normal tissues such as mucosal surface of
`the stomach, trachea and bladder, exocrine glands of the pan-
`creas and the colloid of the thyroid gland do express L& antigen’,
`no drug-related side effects on these organs were observed. The
`maximum tolerated dose (Mll)) of 1,MII-1 was defined as 75
`.ng/kg three times every other day.
`Antitumor activity was observed in 5 patients, 18 patients had
`stable disease, 15 patients progressed. A complete remission last-
`ing two months was observed in a 40-year-old female with
`metastatic breast cancer to the supraclavicular lymph nodes. This
`patient received two cycles of LMB-1 at 15 rig/kg. Shrinkage of
`supraclavicular node was observed five to seven days after the
`first dose of LMB-1. A greater than 75% tumor reduction was ob-
`served in a 50-year-old male with extensive metastatic colon
`cancer to the abdomen and supraclavicular lymph nodes. Tumor
`shrinkage was observed after one single dose of LMB-1 at
`90 jig/kg. Because this patient did not develop antibodies, he re-
`ceived three additional cycles of LMB-1 at a 50% dose (45 jig/kg)
`(Fig. 1). The dose was reduced because of grade 3 toxicity after
`cycle 1. Computed tomography (Cl’) scan of the abdomen
`showed that the tumor continued to decrease in size after each
`cycle. This patient has been followed without evidence of disease
`progression for seven months. Before therapy, the patient com-
`plained of chronic diarrhea and abdominal pain, which required
`therapy with acetaminophen plus codeine. Symptoms resolved
`completely after treatment. Minor responses (<25% decrease in
`tumor size) were observed in three additional patients who re-
`ceived 10, 75 and 90 fig/kg. One colon cancer patient had
`shrinkage of pulmonary nodules lasting for up to nine months.
`Minor responses were observed in two other patients, one colon
`cancer patient with transient decrease of an inguinal mass lasting
`for less than four weeks and a breast cancer patient with adrenal
`metastasis had less than 50% tumor reduction lasting more than
`two months. In all cases, tumor shrinkage was observed within
`the first month after treatment. Stable patients who could not be
`retreated because they developed antibodies against LMB-1 were
`
`Fig. 1 Abdominal computed tomogram of colon cancer patient
`with abdominal metastasis. Upper scan shows extensive retroperi-
`toneal adenopathy before therapy. Lower scan followed two cycles
`of LMB-1 and shows marked tumor shrinkage. This patient received
`two additional cycles of LM8-1 with continuous shrinkage of the
`tumor (>6 months).
`
`NATURE MEDICINE, VOLUME 2, NUMBER 3, MARCH 1996 (cid:9)
`
`351
`
`IMMUNOGEN 2308, pg. 2
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`
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`
`ARTICLES
`
`followed until disease progression. The median time to disease
`Progression was three months (range two to four months).
`Of 38 patients, 33 (90%) developed neutralizing antibodies
`against LMB-1 three weeks after one cycle of treatment. Three
`patients received two cycles of LMB-1 (10, 15, 60 rig/kg) and one
`.tg/kg). Enzyme-linked im-
`patient received four cycles (90, 45
`munosorbent assays (ELISA) indicated that all patients (38/38)
`developed antibody titers against PE38 and 33/38 had antibody
`titers against monoclonal antibody B3. We conclude that al-
`though all patients formed antibodies against the toxin moiety,
`these antibodies have no neutralizing effect against the LMB-1 in
`15% of the cases. Based on the five responses observed in this
`trial, we plan phase 2 studies for colon, breast and other Le’ -
`containing malignancies.
`Our data clearly show that imrnunotoxiri LMB-1 has antitu-
`mor activity in heavily pretreated cancer patients. By using
`recombinant DNA technology we have selected a mutant form
`of PE that is less toxic to patients. Although immunotoxin ther-
`apy has been investigated for two decades, this is the first time
`that objective antitumor activity against metastatic colon and
`breast cancers has been documented. At the MID, side effects of
`LMB-1 were well tolerated and transient. The major side effect,
`VLS, is secondary to targeting of LMB-1 to antigen-positive en-
`dothelial cells".
`Immunotoxins are foreign proteins and highly immunogenic.
`Antibodies can generally be detected 7 to 14 days after the initial
`exposure. These antibodies neutralize the activity of the im-
`munotoxin, precluding a multiple course therapy. Strategies
`presently being explored to overcome this problem are to iden-
`tify and mutate highly immunogenic regions of the toxin" or to
`modify the toxin chemically with polyethylene glycol, as has
`been done for L-asparaginase"’ 4. Concomitant use of 1,MB-1 and
`immunosuppressive agents such as cyclophosphamide, cy-
`closporine, or high-dose corticosteroids needs to be explored.
`It is not clear why some tumors are sensitive to LMB-1 and
`others are not. There are several factors that could contribute.
`One is that the MTD in humans (75 .Lgfkg three times) is less
`than the dose that regularly causes tumor regression in animal
`models’. If higher doses could be given to humans, more re-
`sponses might be observed. Other possibilities are differences in
`tumor penetration due to variations in vascular permeability,
`differences in interstitial pressures in tumors", and differences
`among the cell surface glycoproteins to which Le’ is attached.
`The latter is important because LMB-1 must bind to glycopro-
`teins that are internalized for It to kill cells. The majority of the
`patients treated in our study had large bulky tumors into which
`antibodies and immunotoxins enter slowly.
`Several strategies are being pursued to increase the responses
`to LMB-1. One is to give more doses. A second is to treat patients
`with smaller tumors. A third is to produce a smaller immuno-
`toxin that can penetrate into tumors more effectively. Genetic
`engineering has been used to make LMB-7 (B3(Fv)-PE38) which
`is a small single-chain counterpart of LMB-1 with a molecular
`mass of 65 kD. It is composed of the Fv portion of monoclonal
`antibody B3 fused to the toxin". This agent is more active than
`LMB-1 in animal models. A phase I trial using this second gener-
`ation recombinant immunotoxin is now in progress at the
`National Cancer Institute, National Institutes of Health.
`
`Methods
`Patients eligible for this study have a histologic diagnosis of a malig-
`nant solid tumor and have exhausted the standard therapeutic
`
`352 (cid:9)
`
`options for their disease, or have a malignant disease for which no
`established therapy exists. The tumors must express the 83 antigen
`on the surface of >30% of the cells. The patients must not have
`neutralizing antibodies to LM8-1, must be 18 years or older, have a
`Karnofsky performance status of >80%, have adequate bone mar -
`row (absolute granulocyte count ~!2,000/mm’, platelet count
`~1 00,000/mm’), liver (normal bilirubin, aspartate aminotransf erase
`(SGOT) and alanine aminotransferase (SGPT) <2.5 x normal), and
`kidney (creatinine level <1.5 mg/dl) function. Patients had no
`chemotherapy or radiation therapy within four weeks of entry on to
`this study (eight weeks for drugs with delayed toxicity such as ni-
`trosoureas or mitomycin). All patients have given written informed
`consent in accordance with Federal and institutional guidelines.
`Before therapy, a medical history, physical examination, complete
`blood cell (CBC) count, biochemical profile, urinalysis, electrocardio-
`gram, chest X-ray and scans required for tumor measurement were
`obtained. Patients were monitored weekly with CBC, biochemical
`profile and serum antibodies against 1MB-1 for four weeks. Toxicity
`was reported using the Common Toxicity Criteria, Clinical Trials
`Evaluation Program, National Cancer Institute. For vascular leak syn-
`drome the following grading was used: grade 1, reduced serum
`albumin and fluid retention (A); grade 2, (A) + reduced blood pres-
`sure (BP) not requiring therapy and lasting for <48 h; grade 3, (A) +
`reduced BP for >48 h, requiring fluid replacement; dyspnea on nor-
`mal activity; grade 4, (A) + reduced BP that required pressor agents;
`dyspnea at rest. The MTD is defined as one dose level below that
`which causes unacceptable toxicity in patients on this study. If one
`patient experienced grade 3 or 4 toxicity at a specified dose level,
`additional patients were treated at that level until a total of six pa-
`tients completed one full cycle at the suspect level. If two of six
`patients experienced nonhematologic grade 3 or grade 4 toxicity,
`the suspect level then becomes the level of unacceptable toxicity,
`and the MID is determined to be the level below that.
`Patients were restaged with noninvasive techniques at one month
`after each cycle, and those with progressive disease removed from
`the study. A complete response was defined as the disappearance of
`all clinical evidence of tumor for a minimum of four weeks. Partial re-
`sponse was defined as a decrease of 50% or more in the sum of the
`products of all diameters of measured lesions for a minimum of four
`weeks without the appearance of any new lesions. Minimal response
`was defined as a decrease of less than 50% in any tumor and/or any
`response lasting for less than four weeks. Stable disease was defined
`as a steady state. Progression was defined as the unequivocal in-
`crease of at least 25% in the size of any measurable lesion or
`appearance of new lesions.
`
`Treatment plan. LMB-i was constructed by Inland Labs, Houston,
`Texas from monoclonal antibody (mAb) B3 provided by Verax Co.
`(Lebanon, New Hampshire) and NLysPE38 purified at National
`Institutes of Health. LM8-1 in phosphate-buffered saline (PBS) is sup-
`plied as a sterile solution, 1 mg/ml in 5-ml vials containing 5 mg of
`1MB-11. The appropriate dose of LMB-1 was diluted in 100 ml of nor-
`mal saline containing 0.2% human serum albumin before therapy.
`LMB-1 was administered over 30 min by intravenous infusion on days
`1, 3 and 5. All patients received a 0.1-mg test dose 30 min before the
`treatment dose. The second and third doses of each cycle were de-
`layed or withheld if any measure of toxicity was grade 2 or greater on
`the scheduled day of administration. Patients with responses or stable
`disease were eligible for additional cycles of therapy at 28-day inter-
`vals provided they had not developed anti-LMB-1 antibodies. For
`grade 3 or 4 toxicity, the dose was decreased by 50% in the subse-
`quent cycles. Stable patients who developed antibodies were
`
`NATURE MEDICINE, VOLUME 2, NUMBER 3, MARCH 1996
`
`IMMUNOGEN 2308, pg. 3
`Phigenix v. Immunogen
`IPR2014-00676
`
`

`
`' 1996 Nature Publishing Group http://www.nature.com/naturemedicine
`........................................................................ ARTICLES ....................................................
`
`
`
`followed at two-month intervals until disease progression.
`B3 antigen expression was evaluated by immunohistochemistry
`using sections derived from paraffin blocks as described 17 . Sections
`were treated by boiling using TUF antigen retrieval solution
`(Kreatech), incubated in a blocking solution (4 .tg/ml goat globulin,
`0,1% saponirs, PBS), followed by 10 jig/ml of mAb 83, affinity-
`purified goat-anti-mouse lgG conjugated to horseradish peroxidase
`(Jackson lmmunoResearch, West Grove, Pennsylvania), detected
`using diaminobenzidine substrate solution and counterstained with
`hematoxylin before postfixation in 1% osmium tetroxide. Well-
`preserved tissues generally showed homogeneous reactivity through-
`out the surface of the section, whereas heavily overfixed tissues
`frequently only showed significant reactivity at the marginal zone on
`the surface of the tissue block. Homogeneity of tumor cell reactivity
`in those cases was evaluated only in these marginal regions. Specific
`83 reactivity appeared as a cell surface and Golgi region pattern.
`Controls included deletion of the B3 antibody, or the use of DO-1
`and anti-p53 monoclonal antibody (Novocastra Laboratories) which
`reacts only with nuclear p53, and not in a cell surface pattern.
`
`mmunogenkity of 1MB-11. Antibodies against LMB-i were as-
`sessed weekly for four weeks then bimonthly using ELISA and serum
`neutralization assays. For the ELISA, 96-well microtiter plates were
`coated with PE38 or mAb B3 and blocked with gelatin (3%). Serum
`samples were added in dilutions beginning at 1/10, followed by per-
`oxidase-conjugated AffiniPure goat anti-monkey and developed
`with ABTS. Samples were scored as positive when the optical density
`was at least twice the background. For the serum neutralization
`assay, LMB-1 was added to serum samples at 5 and 25 ng/mI and
`incubated at 37(cid:176)C for 15 mm. The activity of LMB-1 was assayed by
`incubating the samples with MCF-7 cells and measuring its ability to
`inhibit protein synthesis. Cells were seeded at 1.5 x 10’ cells per mil-
`liliter in 96-well plates, 24 h before the addition of serum containing
`LMB-1, incubated at 37 ’C for 24 h, and then assayed for incorpora-
`tion of [ 3 H]leucine. A standard curve with LMB-1 was used to
`determine mean inhibitory concentration (IC,,). A serum sample was
`considered negative for antibodies against LMB-i when the cyto-
`toxic activity of LMB-i was not neutralized when incubated with
`sera, and positive or strongly positive when the serum sample neu-
`tralized the cytotoxic activity of 5 ng/ml and 25 ng/ml of LMB-1,
`respectively.
`
`Acknowledgments
`We thank D. FitzGerald, M. Gallo and Y. Shiloach for helping to produce
`LMB-1. We thank A. Rutherford for technical assistance and B. Goldspie!
`from the Pharmacy Department of the Clinical Center, National Institutes of
`Health, for his support.
`
`RECEIVED 20 NOVEMBER 1995; ACCEPTED 31 JANUARY 1996
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`NATURE MEDICINE, VOLUME 2, NUMBER 3, MARCH 1996
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`IPR2014-00676