JOURNAL OF INTERFERON AND CYTOKINE RESEARCH 21:257–263 (2001)
`Mary Ann Liebert, Inc.
`
`Randomized Multicenter Phase II Trial of Subcutaneous
`Recombinant Human Interleukin-12 Versus Interferon-a2a for
`Patients with Advanced Renal Cell Carcinoma
`
`ROBERT J. MOTZER,1 ASHOK RAKHIT,3 JOHN A. THOMPSON,4 JOHN NEMUNAITIS,5
`BARBARA A. MURPHY,6 JULIE ELLERHORST,7 LAWRENCE H. SCHWARTZ,2
`WILLIAM J. BERG,1 and RONALD M. BUKOWSKI8
`
`ABSTRACT
`
`Recombinant human interleukin-12 (rHuIL-12) is a pleiotropic cytokine with anticancer activity against re-
`nal cell carcinoma (RCC) in preclinical models and in a phase I trial. A randomized phase II study of rHuIL-
`12 compared with interferon-a (IFN-a) evaluated clinical response for patients with previously untreated, ad-
`vanced RCC. Patients were randomly assigned 2:1 to receive either rHuIL-12 or IFN-a2a. rHuIL-12 was
`administered by subcutaneous (s.c.) injection on days 1, 8, and 15 of each 28-day cycle. The dose of IL-12 was
`escalated during cycle 1 to a maintenance dose of 1.25 l g/kg. IFN was administered at 9 million units by s.c.
`injection three times per week. Serum concentrations of IL-12, IFN-c , IL-10, and neopterin were obtained in
`10 patients treated with rHuIL-12 after the first full dose of 1.25 l g/kg given on day 15 (dose 3) of cycle 1
`and again after multiple doses on day 15 (dose 6) of cycle 2. Thirty patients were treated with rHuIL-12, and
`16 patients were treated with IFN-a. Two (7%) of 30 patients treated with rHuIL-12 achieved a partial re-
`sponse, and the trial was closed to accrual based on the low response proportion. IL-12 was absorbed rapidly
`after s.c. drug administration, with the peak serum concentration appearing at approximately 12 h in both
`cycles. Serum IL-12 concentrations remained stable on multiple dosing. Levels of IFN-c , IL-10, and neopterin
`increased with rHuIL-12 and were maintained in cycle 2. rHuIL-12 is a novel cytokine with unique pharma-
`cologic and pharmacodynamic features under study for the treatment of malignancy and other medical con-
`ditions. The low response proportion associated with rHuIL-12 single-agent therapy against metastatic RCC
`was disappointing, given the preclinical data. Further study of rHuIL-12 for other medical conditions is un-
`derway. For RCC, the study of new cytokines is of the highest priority.
`
`INTRODUCTION
`
`RECOMBINANT HUMAN INTERLEUKIN-12 (rHuIL-12) is a cy-
`
`tokine with a variety of immunomodulatory effects on T
`lymphocytes and natural killer (NK) cells including (1) en-
`hancing the lytic activity of NK lymphokine-activated killer
`(LAK) cells, (2) facilitating specific cytolytic T lymphocyte re-
`sponses, (3) inducing the secretion of interferon-g (IFN-g) by
`both T and NK cells, and (4) promoting the development of
`
`Th1 helper T cells, thereby contributing to the development of
`cell-mediated immune responses.(1–3) rHuIL-12 has also been
`demonstrated to inhibit angiogenesis, which may contribute to
`its antitumor activity.(4) rHuIL-12 has been shown to have strik-
`ing therapeutic effects in a number of mouse tumor models, in-
`cluding the Renca renal cell model,(5) and mouse models of in-
`fectious disease and airway inflammation. On the basis of these
`studies, clinical trials investigating the potential therapeutic ef-
`fects of rHuIL-12 in the treatment of cancer, human immuno-
`
`1Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, and the 2Department of Medical Imaging,
`Memorial Sloan-Kettering Cancer Center, New York, NY.
`3Hoffmann-La Roche, Inc., Nutley, NJ
`4University of Washington, Seattle, WA
`5US Oncology, Dallas, TX
`6Vanderbilt University, Nashville, TN
`7University of Texas M.D. Anderson Cancer Center, Houston, TX
`8The Cleveland Clinic Foundation, Cleveland, OH
`
`257
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`258
`
`MOTZER ET AL.
`
`deficiency virus (HIV) infection, chronic viral hepatitis, and
`asthma were initiated.
`IFN-a and IL-2 have a low level of antitumor effector against
`renal cell carcinoma (RCC).(6,7) As this malignancy is associ-
`ated with a poor prognosis and is chemotherapy resistant,(8) the
`study of new cytokines is a priority. A phase I trial of rHuIL-
`12 was conducted in patients with advanced RCC using two
`schedules, as a fixed dose an an uptitration schedule, whereby
`the dose of rHuIL-12 was increased for each patient to a target
`dose.(9) The study showed antitumor activity against metasta-
`tic RCC and improved tolerability for the uptitration schedule
`and suggested a dose suitable for phase II study.(9) The phar-
`macokinetic and pharmacodynamic studies showed that serum
`levels of IL-12, IFN-g, and IL-10 produced in response to
`IL-12 were all highest in the week after the first dose of rHuIL-
`12, were dose related, and decreased after long-term adminis-
`tration when rHuIL-12 was administered as a fixed dose.(10)
`Clinical responses associated with rHuIL-12 treatment
`against RCC were reported in phase I trials conducted by oth-
`ers, as well.(11–14) To further define efficacy, toxicity, and phar-
`macology, we conducted a randomized phase II trial of rHuIL-
`12 in patients with RCC. Patients were randomized to receive
`rHuIL-12 by an uptitration schedule based on our phase I trial(9)
`or IFN-a2a (Roferon®-A) (Hoffman-La Roche, Inc., Nutley,
`NJ). A proportion of patients treated with rHuIL-12 had phar-
`macologic and pharmacokinetic studies performed. The results
`of this trial and these studies follow.
`
`rHuIL-12 therapy
`
`rHuIL-12 was supplied by Hoffman-La Roche, Inc., as
`ready-to-use human serum albumin (HAS)-free solution in
`single-use glass vials in three concentrations: 10, 50, and 100
`mg/ml purified rHuIL-12 in 1 ml sterile solution containing
`polysorbate 80 (0.2 mg/ml) and 67 mM phosphate-buffered
`saline (PBS) adjusted to pH 7.0. The vials were stored at 2–8°C
`and protected from light. rHuIL-12 was administered by sub-
`cutaneous (s.c.) injection using a 25G needle.
`Patients were treated by s.c. injection on days 1, 8, and 15
`of each 28-day cycle. The dose was escalated during the first
`cycle: day 1 dose 5 0.1 m/kg, day 8 dose 5 0.5 mg/kg, and day
`15 dose 5 1.25 mg/kg, with a maximum dose of 100 mg. Dur-
`ing subsequent cycles, all treatment was administered at a main-
`tenance dose of 1.25 mg/kg. Treatment was delivered on an out-
`patient basis except when pharmacokinetic studies were being
`performed. Patients were treated until disease progression or
`unacceptable toxicity. The treatment dose was modified for tox-
`icity according to a nomogram.
`
`IFN-a therapy
`
`IFN-a2a (Roferon®-A) was supplied by Hoffmann-La
`Roche, Inc., as ready-to-use, HSA-free solution in single-use
`glass vials. IFN-a2a was administered by s.c. injection at a dose
`of 9 million units three times each week. Dose modifications
`were based on toxicity grade.
`
`PATIENTS AND METHODS
`
`Patient follow-up
`
`Patients
`
`Forty-six patients with advanced RCC were accrued from six
`centers to this Institutional Review Board-approved clinical trial
`between February and May 1997. All patients entered in the
`trial gave informed consent. They were required to have mea-
`surable disease, Karnofsky performance status $80%, white
`blood cell (WBC) count $3000 cells/mm3, granulocytes $2000
`cells/mm3, platelet count $75,000/mm3, hemoglobin $9 g/dl,
`serum bilirubin #1.5 times normal, transaminase levels and al-
`kaline phosphatase $2.5 times normal, serum creatinine con-
`centration #1.5 times normal, and PT/PTT within normal lim-
`its. Exclusion criteria included prior systemic treatment for RCC,
`active brain metastases, history of psychiatric disabilities or
`seizures, clinically significant comorbid conditions, active in-
`fection, and a history of any Th1-mediated autoimmune disease.
`
`Trial design
`
`Patients were prospectively randomized to receive treatment
`with either rHuIL-12 or IFN-a. The ratio of assignment for
`treatment with rHuIL-12 to IFN-a was 2:1. The target accrual
`was 80 patients treated with rHuIL-12 and evaluated for re-
`sponse. If an objective tumor response rate of 25% occurred in
`80 patients, the 95% confidence interval (CI) would range from
`16.0% to 35.9%. Thus, the lower limit of normal would be sim-
`ilar to the response rate induced by other therapies.(8) No for-
`mal interim analysis was planned, but an early stopping rule
`was implemented by the sponsor based on a low response pro-
`portion observed in the rHuIL-12 arm.
`
`Patients were seen and examined at periodic intervals, with
`laboratory evaluation that included hematologic, coagulation,
`and biochemistry panels. Tumor assessments were made after
`
`TABLE 1. RESULTS OF CLINICAL TRIAL
`
`Characteristic
`
`Patients
`Males (%)
`Females (%)
`Median age (range)
`Nephrectomy (%)
`Total (%)
`Partial (%)
`Disease sites (%)
`One (%)
`Two (%)
`Three or more (%)
`Response
`Evaluable
`Favorable (partial)
`response (%)
`Toxicity: grade $3
`Flu-like symptoms (%)
`Liver function test
`elevation (%)
`Neutropenia (%)
`Ascites (%)
`Stomatitis (%)
`
`rHuIL-12
`No.
`
`30
`18 (60)
`12 (40)
`55 (40–77)
`16 (53)
`15 (50)
`1 (3)
`
`8 (27)
`6 (20)
`16 (53)
`
`29
`
`2 (7)
`
`3 (10)
`
`2 (7)
`1 (3)
`1 (3)
`1 (3)
`
`IFN-a
`No.
`
`16
`9 (56)
`7 (44)
`60 (41–70)
`9 (56)
`8 (50)
`1 (6)
`
`1 (6)
`4 (25)
`11 (69)
`
`14
`
`0 (0)
`
`1 (7)
`
`1 (7)
`0 (0)
`0 (0)
`0 (0)
`
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`PHASE II TRIAL OF IL-12
`
`259
`
`every two cycles. Responses were graded according to the
`World Health Organization (WHO) Criteria, and toxicity was
`graded by the National Cancer Institute (NCI) Common Tox-
`icity Criteria.
`
`Pharmacodynamic and pharmacokinetic methods
`
`Serum concentrations of rHuIL-12 were measured at base-
`line, and 4, 6, 8, 10, 12, 16, 20, 24, 30, 36, and 48 h after dos-
`ing on day 15 of the first two cycles in 10 patients treated at
`two of the centers. rHuIL-12 concentration was measured by a
`two-step method of antibody capture to insure specificity, fol-
`lowed by a cell proliferation assay. rHuIL-12 was isolated from
`serum by an affinity technique that involved incubation of sam-
`ples in sterile tissue culture plates precoated with mouse anti-
`human IL-12 monoclonal antibody (mAb).(15) The method has
`been described previously.(9,10)
`IFN-g, neopterin, and IL-10 concentrations were measured in
`the serum of 10 patients at preselected times. Serum samples
`were obtained at baseline and 10, 24, 48, 72, 96, and 168 h
`after treatment on day 15 of the first two cycles of treatment.
`IFN-g concentrations in serum were determined by a commer-
`cial assay (R&D Systems, Minneapolis, MN). Neopterin con-
`centration in serum was measured using a radioimmunoassay
`that used 125I-neopterin as a tracer (Incstar, Stillwater, MN).
`Serum IL-10 was measured by an ELISA with a commercial
`assay (Boehringer Mannheim, Mannheim, Germany). The
`methodologies have been described previously.(9,10)
`Serum concentration compared with time data was analyzed
`for rHuIL-12 and other immunologic markers by a noncom-
`partmental model.
`
`RESULTS
`
`Clinical trial
`
`Forty-six patients were enrolled (Table 1). Thirty patients
`were randomized to treatment with rHuIL-12, and 16 were ran-
`domized to treatment with IFN-a2a. The median age was 55
`years on the rHuIL-12 arm and 60 years on the IFN-a2a arm.
`Approximately one half of all patients had a prior nephrectomy.
`Two of 29 (7%, 95% C.I. 0-16%) evaluable patients treated
`with rHuIL-12 achieved a partial response. One patient who re-
`sponded had prior nephrectomy with lung-only metastases, and
`the second patient had prior nephrectomy with three metastatic
`sites, lung, bone, and skin. No patient treated with IFN-a2a
`achieved a partial or complete response. Based on the low re-
`sponse to rHuIL-12, accrual to the trial was stopped.
`The most common toxicity associated with rHuIL-12 was
`flu-like symptoms. Grade 3 or 4 elevation of hepatic transam-
`inases occurred in 2 (7%) patients receiving rHuIL-12 and 1
`(7%) receiving IFN-a2a. Other severe toxicities occurring on
`the rHuIL-12 arm were neutropenia, ascites, and stomatitis.
`
`Pharmacokinetic studies
`
`Serum concentrations of IL-12 were obtained in 10 patients
`treated with rHuIL-12 at two centers participating in this study.
`Because of gradual dose escalation in the first cycle of treat-
`ment, serum concentrations were measured after the first full
`dose of 1.25 mg/kg given on day 15 (dose 3) of cycle 1 and
`again after multiple doses on day 15 (dose 6) of cycle 2. IL-12
`was absorbed rapidly after s.c. administration, with peak serum
`concentration noted at about 12 h in both cycles. We reported
`
`500
`
`450
`
`400
`
`350
`
`Cll!,le 2 D!!l£ 15
`
`E --O> a. 300
`-N
`::, ... Q)
`
`T"""
`I
`...J
`E
`
`(f)
`
`250
`
`200
`
`150
`
`100
`
`50
`
`0
`0.00
`
`10.00
`
`20.00
`
`30.00
`Time (hr)
`
`40.00
`
`50.00
`
`60.00
`
`FIG. 1. Mean (6SE) serum concentrations of IL-12 in RCC patients after 1.25 mg/kg/week s.c. administration of rHuIL-12 us-
`ing a slow dose escalation scheme.
`
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`260
`
`MOTZER ET AL.
`
`TABLE 2. COMPARISON OF PHARMACOKINETIC AND IMMUNOLOG IC SURROGATE PARAMETERS IN
`CYCLE 1 VS. CYCLE 2 AFTER ADMINISTRATION OF rHUIL-12 IN RCC PATIENTS
`
`Analyte
`
`IL-12
`Mean
`SE
`IFN-g (pg/ml)
`Mean
`SE
`IL-10 (pg/ml)
`Mean
`SE
`Neopterin (ng/ml)
`Mean
`SE
`
`Cmax
`Dose 3
`Dose 6
`
`Tmax (h)
`Dose 3
`Dose 6
`
`AUC
`
`Dose 3
`
`Dose 6
`
`384
`88
`
`170
`39
`
`65
`8
`
`432
`112
`
`146
`33
`
`96
`13
`
`8.65
`1.37
`
`10.34
`1.67
`
`15
`4
`
`30
`5
`
`36
`5
`
`80
`14
`
`10
`1
`
`20
`5
`
`25
`3
`
`69
`6
`
`10,646 pg ? h/ml
`2,583
`
`11,031
`2,886
`
`7,982 pg ? h/ml
`2,185
`
`6,483 pg ? h/ml
`1,373
`
`793 ng ? h/ml
`154
`
`6,011
`1,525
`
`9,345
`1,403
`
`1,306
`336
`
`that serum concentrations of IL-12 decreased gradually after
`multiple doses in a fixed-dose scheme.(10) In contrast, the cur-
`rent study showed serum IL-12 concentrations were stable on
`multiple dosing when drug was administered in the slow dose-
`escalation pattern (Fig. 1). The maximum serum concentrations
`of IL-12 were maintained at comparable levels in cycles 1 and
`2 (dose 3, 384 pg/ml, vs. dose 6, 432 pg/ml). Serum area un-
`der the curve (AUC) during the dosing interval was also main-
`tained on multiple dosing (dose 3, 10,646 pg/ml, vs. dose 6,
`11031 pg/ml). Individual pharmacokinetic parameters were
`compared for dose 3 (cycle 1) vs. dose 6 (cycle 2) (Table 2).
`
`Pharmacodynamic studies
`
`Three immunologic surrogate markers were monitored in the
`serum of the 10 patients treated with rHuIL-12 (Table 2). Serum
`IFN-g increased after IL-12 dosing, with peak concentrations
`
`appearing at about 24 h into both cycles 1 and 2. Serum IFN-g
`was not measurable at predose baseline in any of these patients.
`Similar to IL-12, the average peak serum concentration of
`IFN-g was relatively unchanged (170 vs. 146 pg/ml) between
`the two cycles (Fig. 2). Five patients showed a small decrease,
`and 4 patients’ peak concentration increased slightly. Serum
`samples could not be obtained in 1 patient in cycle 2.
`The concentration of neopterin increased significantly from
`baseline as the dose was increased from 0.5 to 1.25 mg/kg/week
`in cycle 1, but induction was maintained at comparable levels
`as the 1.25 m/kg dose was maintained on subsequent cycles
`(dose 3 vs. dose 6: Cmax 8.65 vs. 10.34 ng/ml, and AUC 793
`vs. 1306 ng ? h/ml), demonstrating maintenance of the immuno-
`logic activity of rHuIL-12 in these patients at the end of 2
`months treatment (Fig. 3).
`Serum concentrations of IL-10 increased after administration
`of rHuIL-12. Peak serum IL-10 concentrations appeared be-
`
`200
`
`180
`
`160
`
`- 140
`E -C) 120
`
`.e,
`~ z 100
`!±
`E
`::::, ... Q)
`
`80
`
`60
`
`Cl)
`
`40
`
`20
`
`0
`
`0
`
`20
`
`40
`
`60
`
`100
`80
`Time (hr)
`
`120
`
`140
`
`160
`
`180
`
`FIG. 2. Maintenance of serum concentrations of IFN-g after s.c. administration of 1.25 mg/kg/week of rHuIL-12 in RCC pa-
`tients given in a slow dose escalation scheme.
`
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`NOVARTIS EXHIBIT 2075
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`

`PHASE II TRIAL OF IL-12
`
`261
`
`25 ~ - - - - - - - - - - - - - - - - - - - - - - - - - -~
`
`20
`
`C:
`
`:::::-
`E ---0)
`~ 15
`·.:::
`Cl>
`C.
`0
`Cl> z 10
`E
`....
`:::J
`Cl>
`(/)
`
`Cycle 1 Dav 15
`
`5
`
`0-+----~---r------r------,-------r------,---,----~------j
`60
`120
`20
`40
`80
`100
`140
`160
`180
`0
`Time (hr)
`
`FIG. 3. Mean (6SE) serum concentrations of neopterin after s.c. administration of 1.25 mg/kg/week of rHuIL-12 in RCC pa-
`tients given a slow dose escalation.
`
`tween 24 and 48 h of IL-12 administration in both cycles. Sim-
`ilar to IL-12 and IFN-g, IL-10 concentrations did not decrease
`on multiple dosing in this study. The mean Cmax and AUC in-
`creased to a small but significant extent (p , 0.05 by paired t-
`test) (Fig. 4).
`
`DISCUSSION
`
`This randomized phase II trial stopped accrual after an in-
`terim analysis showed a low response proportion associated
`with rHuIL-12 treatment in previously untreated patients with
`
`120
`
`100
`
`E 80
`---0)
`-9:
`0 ..... 60
`I
`...J
`E
`:::,
`.... 40
`Q)
`Cl)
`
`20
`
`0
`
`0
`
`20
`
`40
`
`60
`
`100
`80
`Time (hr)
`
`120
`
`140
`
`160
`
`180
`
`FIG. 4. Mean (6SE) serum concentrations of IL-10 after s.c. administration of 1.25 mg/kg/week of rHuIL-12 in RCC patients
`given a slow dose escalation scheme.
`
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`262
`
`MOTZER ET AL.
`
`advanced RCC. The low response proportion was consistent
`with the results of the phase I trial, whereby 1 (2%) of 50 pa-
`tients achieved a partial response.(9) However, that trial included
`patients treated with lower doses according to a phase I trial
`design, and approximately 60% had progressed through prior
`cytokine therapy. The current study was undertaken to define
`activity in cytokine-naive patients treated at an optimal dose
`and schedule derived from the phase I trial. Nevertheless, the
`antitumor activity of rHuIL-12 was disappointing, given the
`high degree of response observed with rHuIL-12 in the mouse
`RCC model.(5) Ongoing studies are addressing the efficacy of
`combination treatment using rHuIL-12 with IL-2, as synergy
`for the two cytokines was shown in animal studies.(16)
`In the first part of the phase I trial, rHuIL-12 was adminis-
`tered in fixed weekly doses, and serum concentrations de-
`creased rapidly on multiple dosing.(10) The extent of reduction
`in serum AUC was observed to be dependent on the initial rate
`of exposure. Similar to serum profiles of IL-12, the immuno-
`logic markers IFN-g, IL-10, and neopterin showed a gradual
`decrease on chronic dosing, suggesting a potential downregu-
`lation of the cytokine cascade. This was consistent with the clin-
`ical findings, as adverse events (e.g., fever, fatigue) also de-
`creased in intensity with chronic administration of the drug.
`These observations in the phase I trial led us to study a grad-
`ual dose-escalation scheme to potentially reduce acute adverse
`events (first-dose toxicity) and allow better adaptation of this
`cytokine, thereby reducing the extent of regulatory feedback re-
`sponse.(9) In the current phase II study, patients were treated
`with a slow dose-escalation scheme of 0.1 mg/kg in week 1,
`then 0.5 mg/kg in week 2, followed by a maintenance dose of
`1.25 mg/kg/week during the rest of the treatment period. In con-
`trast to observations from a fixed dosing scheme,(9,10) the serum
`concentration of IL-12 appeared to be maintained in cycle 2
`compared with that observed after the first full dose of 1.25
`mg/kg given in week 3. When compared with first-dose Cmax
`given at 1 mg/kg in an earlier fixed-dose study,(10) concentra-
`tions in the current study were lower, at 1.25 mg/kg dose, sug-
`gesting that the influence of regulatory feedback was still pres-
`ent in this dosing scheme. The Cmax for the fixed first dose of
`1 mg/kg in the phase I trial was 1092 6 SE 275 pg/ml(10) com-
`pared with the first escalation dose of 1.25 mg/kg 384 6 88
`pg/ml in the current study. Therefore, IL-12 exposure may not
`necessarily have been gained by this dosing scheme. However,
`tolerability was improved substantially, as toxicity was unac-
`ceptable in the first dose of the fixed schedule at doses .0.5
`mg/kg.(9)
`Three different immunologic surrogate markers were moni-
`tored in the serum of these 10 patients treated with rHuIL-12.
`Serum IFN-g, a well-recognized Th1 marker of IL-12 activity,
`increased after IL-12 dosing, with peak concentration appear-
`ing at about 24 h; the average peak serum concentration was
`similar between the two cycles. Neopterin, a marker for mac-
`rophage activation, was induced by rHuIL-12 in all patients
`monitored. Similar to IL-12, IFN-g and neopterin did not de-
`crease on multiple dosing in this study, suggesting that immune
`activity was maintained. IL-10 levels increased following
`rHuIL-12 administration. IL-10 can inhibit the synthesis and
`action of IL-12.(17,18) Therefore, the ability of rHuIL-12 to in-
`duce IL-10 production could represent a negative feedback
`mechanism by which IL-12 limits its own effects.
`
`In summary, rHuIL-12 has unique pharmacologic and phar-
`macokinetic properties that warrant further study for patients
`with malignancy and other medical conditions. The lack of an-
`titumor activity for single-agent rHuIL-12 against RCC in this
`study was disappointing, given promising preclinical data. For
`RCC, the study of new cytokines is of the highest priority.
`
`ACKNOWLEDGMENTS
`
`We thank Lucy Dantis, Patricia Fischer, and the immunol-
`ogy nursing staff for nursing support and Carol Pearce for her
`review of the manuscript.
`
`REFERENCES
`
`1. BANKS, R.E., PATEL, P.S., and SELBY, P.J. (1995). Interleukin-
`12: a new clinical player in cytokine therapy. Br. J. Cancer 71,
`655–659.
`2. BRUNDA, M.J. (1997). Interleukin-12. J. Leukocyte Biol. 55,
`280–288.
`3. GALETTI, T.P. (1993). Interleukin-12: a recently discovered cy-
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`
`Address reprint requests to:
`Dr. Robert J. Motzer
`Memorial Sloan-Kettering Cancer Center
`1275 York Avenue, Howard 906
`New York, NY 10021
`
`Tel: (212) 639-6667
`Fax: (212) 717-3133
`E-mail: motzerr@mskcc.org
`
`Received 27 October 2000/Accepted 9 January 2001
`
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