`
`
`
`
`
`Vol. I. 965-972. September 1995
`
`Cancer Research 965
`Clinical
`
`Phase I Clinical Trial of Serotherapy in Patients with Acute Myeloid
`
`
`Leukemia with an Imm unoglobulin M Monoclonal
`Antibody to CD151
`
`Edward D. Ball,2 Kathy Selvaggi, David Hurd,
`Roger Herzig, Laura Clark, Vicki Malley,
`Jeannette Persichetti, and
`Margarida deMagelhaus-Silverman
`Division of Hematology/Bone Marrow Transplantation, Univer.;ity of
`Pittsburgh Medical Center, Pitlsburgh, Pe nnsylvania 15213 [E. 0. B .•
`K. S .. LC.. V. M .. J. P., M. 0. S.): Bowman-Gray Medical Center.
`Winston-Salem, Nonh Carolina 27103 (D. H.); and Univer.;ity of
`Louisville, Louisville, Kentucky 40292 (R. H.)
`
`INTRODUCTION
`mAbs have been used in the treatment of malignancies
`
`
`
`
`
`expressing tumor-associated antigens. It is necessary for the
`
`
`mAb to have an effector mechanism, such as the ability to
`
`
`activate complement (C') or mediate antibody-dependent cellu­
`
`or 10 carry a cytotoxic agent, such as a radio­
`lar cytotoxicity,
`
`
`isotope, drug, or toxin, to allow for killing of lumor cells. mAbs
`
`
`which regulate ligand/receptor in1eractions that lead to cell
`
`
`death through indirect mechanisms or stimulate programmed
`cell death (such as apoptosis) could also be used therapeutically.
`trials of in vivo mAb
`In one of the early and most encouraging
`ABSTRACT
`
`therapy, a patient with B-cell non-Hodgkin's lymphoma
`
`
`
`achieved complete remission, lasting for several years after
`Sixteen patients with acute myeloid leukemia (AML)
`
`
`
`treatment with an antiidiotype mAb (1). Studies in patients with
`were treated with a continuous i.v. infusion of mAb PM-81,
`
`AML3 using the mAb Ml95 (reactive with CD33) labeled with
`an lgM mAb directed against the cellular differentiation
`
`
`
`iodine-131 have also met with success in transient reductions of
`antigen COIS, which is expressed on leukemia cells of >95%
`
`tumor cells. In some cases, cytoreduction was significant
`of patients with AML. MAb PM-81, also referred to as
`
`enough for patients to proceed to bone marrow transplant.
`MOX-11, is capable of activating human and rabbit comple­
`
`Whole-body imaging for radiolocalization and bone marrow
`ment and lysing CDIS-positive AML cells. In this Phase I
`biopsies showed M195 uptake in the bone marrow, liver, and
`study, patients were treated with O.S, 1.0, or l.S mg/kg
`
`spleen as early as 1 h after infusion (2, 3). Many researchers
`MDX-11 delivered over a 24-h period followed by conven­
`have also used chimeric and humanized mAbs to reduce toxic­
`tional chemotherapy. Transient decreases in circulating
`
`
`in ities and promote antibody-dependent cellular cytotoxicity
`
`blast cells postinfusion (prior to chemotherapy) were ob­
`
`various malignancies (4-6).
`served at all doses. We were able to show MOX-11 binding
`We have previously described the mAb PM-81 (anti­
`
`
`to bone marrow blasts in those patients who achieved stable
`
`
`CD15), subsequently referred to as MDX-11, which is reactive
`serum levels of MDX-11. Serum MOX-11 was detectable at
`
`with leukemia cells from >95% of patients with AML. The
`the 1.0- and l.S-mg/kg doses. Doses of O.S and 1.0 mg/kg
`
`epitope recognized by anti-CD15 antibodies is a trisaccharide
`were generally well tolerated, with no toxicities greater than
`LNF-111 (also referred
`
`structure within the penlasaccharide
`to as
`grade II (Eastern Cooperative Oncology Group) reported.
`LNFP-111, Lewis x, or SSEA-1). CD15 is found on neutrophils,
`However, two of five patients receiving the l.S-mg/kg dose
`
`
`
`eosinophils, and monocytes, and is present in embryonic tissues,
`experienced grade IV toxicities that resolved with treatment
`adenocarcinomas,
`
`and myeloid leukemias. Thus, MDX-11 is
`(one of these patients completed the infusion). Common
`
`
`reactive with normal granulocytes and monocytes. MDX-I I is
`toxicities reported included fever, chills, and hypotension.
`
`
`not reactive with lymphocytes or the colony-forming unit-gran­
`
`
`
`ulocyte-monocyte or burst-forming unit-erythroid (7, 8). This
`Only one patient developed human antimouse antibodies at
`4 weeks posttreatment. This study determined that 1.0
`
`mAb is an lgM antibody capable of activating both rabbit and
`mg/kg is a biologically effective dose that can be adminis­
`
`human complement (9). Although MDX-11 is cytotoxic to early
`te.red safely with little toxicity. Based on these results, we are
`
`malignant myeloid leukemia precursors and some normal my­
`
`
`
`eloid precursors. pluripotent stem cells are unaffected (9, 10).
`pursuing a Phase I/II study of MDX-11 infusion following
`
`Studies exploring the use of MDX-11 as a therapeutic
`chemotherapy for patients with relapsed AML.
`
`An early Phase I clinical trial was per­
`agent are in progress.
`
`
`formed in which three patients with AML with resistant disease
`in relapse were given up to 500 mg MDX-I I in vivo. All
`
`Received 3/23195; revised 5/15195; accepted 5/30/95.
`1 This project was supponed in pan by Grant CAJ 1888 from the
`National Cancer Institute, NIH, Depanment of Health and Human
`Services (Bethe sda. MD) and by Medarex, Inc. (Annandale, NJ).
`2 To whom requests for reprints should be addressed,
`at Division of
`Hematology/Bone Marrow Transplantation, Univer.;ity of Pittsburgh
`Medical Center, 200 Lo throp Street, Pittsburgh. PA 15213.
`
`3 The abbreviations used are: AML. acute myeloid leukemia; ABMT,
`autologous bone marrow transplantation; gam, goat anlimousc; NHS,
`normal human scrum; HAMA. human anlimousc antibodies; PBA,
`phosphate-buffered saline/bovine scrum albumin/sodium azide; LNFP-
`111, lacto-N-fucopcntaosc Ill; ECOG, Eastern Cooperative Oncology
`Group.
`
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`
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`
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`

`

`966 Phase I Clinical Trial of Serotherapy in Patients with AML
`
`patients experienced an approximate 25% transient decrease in
`leukemic blast counts with little toxicity (11). MDX-I I has also
`been used, along with an anti-CDl 4 mAb (AML-2-23), for ex
`vivo treatment of bone marrow for ABMT for patients with
`AML (12, 13). The results of this study have been encouraging
`and a randomized trial is being planned.
`Despite successes with ABMT in the treatment of AML, it
`is important to note that up to 50% of patients with transplants
`eventually relapse, implying that the ablative therapies used to
`prepare patients for transplant fail to remove all leukemia cells.
`And while most of the in vivo mAb serotherapies used in
`leukemias to date have shown promise in transient reductions of
`tumor burden, few cases of complete or partial remissions have
`been reported (14, 15). With this in mind, and because of the
`limited toxicities associated with mAb serotherapies, we are
`evaluating the role of MDX-I I mAb serotherapy for the treat­
`ment of AML as an adjunct to standard chemotherapy and for
`post-ABMT immunotherapy. The objectives of this Phase I
`study were to establish safety, feasability, and optimal biologi­
`cal dose of MDX-11. The study design included treating patients
`with relapsed or secondary AML with escalating doses of
`MDX-I I using a continuous i.v. infusion over 24 h followed by
`conventional chemotherapy.
`
`MATERIALS AND METHODS
`mAb
`MDX-I I (Medarex, Inc., Annandale, NJ) was prepared for
`clinical use under the United States Food and Drug Adminis­
`tration IND 4362. MDX-11 is manufactured using a hollow
`fiber bioreactor and purified by ion exchange using HPLC.
`Supernatant is filtered during the manufacturing process and at
`the end of purification following buffer exchange by column.
`Final purified antibody is monitored for quality control using
`HPLC and SOS gels for identity and purity, for activity using
`binding and specificity assays (flow cytometry) and cytotoxicity
`assays, and for general safety by detennining DNA levels,
`endotoxin levels, perfonning viral testing, and general animal
`safety.
`
`HL60 Cells
`HL60, a CD15-positive leukemia cell line, was obtained
`from the American Type Culture Collection (Bethesda, MD).
`The cells were cultured in RPMI 1640 (GIBCO-BRL, Life
`Technologies, Grand Island, NY) with 10% FCS (Hyclone,
`Logan, UT), and L-glutamine, penicillin, streptomycin, and gen­
`tamicin.
`
`Serum MDX-11 Determination
`Serum MDX-11 levels were detennined using a sandwich
`ELISA which incorporated gam-lgM in the solid phase, patient
`sera as the intermediate step, and alkaline phosphatase-conju­
`gated gam-lgM as the final labeled antibody. Blood samples
`were obtained from patients at screening, and before, during,
`and after infusion. Briefly, 96-well plates were coated overnight
`at 4°C with I µg gam-lgM, washed with PBS, and blocked with
`5% PBA for 45 min to 2 h at 37°C. Standard curve dilutions of
`lgM (30-0.003 mg/ml) were made in 10% NHS. Patient sera
`were diluted I: JO in 1 % PBA; higher dilutions of patient serum
`
`were made in 10% NHS diluted in PBA. Plates were washed
`after blocking, and 100 µ.I of negative control, standard curve,
`and patient serum dilutions were added to the appropriate wells.
`Plates were incubated at 37°C for 1.5 to 3 h. After washing,
`alkaline phosphatase-conjugated gam-lgM was added for 1.5 to
`3 h at 37°C. The plate was then washed and developed with
`p-nitrophenyl phosphate disodium. The reaction was stopped
`with I N sodium hydroxide after 20 min, and the plates were
`read in an ELISA reader (Dynatech MR660) using a 4JOA filter,
`blanking on the negative control wells. Standard curve was
`perfonned in duplicate, patient samples in triplicate. This assay
`was able to detect levels as low as 0.1 µg/ml; levels of MDX-I I
`above 0.5 µg/ml were able to be quantified.
`
`Serum CDIS Determination
`Sera from patients in this study were assayed for soluble
`CDJ5 using a blocking assay which incorporated LNFP-111
`(Oxford Glycosystems, Inc., Rosedale, NY). Blood samples
`were obtained from patients before infusion and at 1 = 24 h (end
`infusion). The CD15 antigen-positive cell line HL60 was har­
`vested, washed, resuspended to 2 X 107/ml in PBA, and stored
`on ice until blocking. The first part of the assay was carried out
`in duplicate in 96-well round-bottomed plates. MDX-11 was
`diluted to 0.75 units/ml in PBA, and 10 µI (0.0075 units) were
`added to each well. A standard curve of LNFP-1 11, 2.0 mg/ml in
`PBS, was made by adding 0.5-10 µI LNFP-111 to the microtiter
`wells containing MDX-I I. For patient samples and NHS, 10 µI
`of undiluted, I :5, and I: 10 dilutions were added to wells con­
`taining MDX-11. Final volumes were brought to 20 µI with
`PBA. For negative controls, 5 µI irrelevant mouse IgM (Coulter,
`Hialeah, FL) and 15 µI PBA were added to the MDX- I I. The
`plate was then incubated at room temperature with shaking for
`30 min. After 15 min, Fe receptors on HL60 cells were blocked
`by adding 1/2 volume of human blocking IgG (10 mg/ml) and
`incubating for IO to 15 min at 4°C (this incubation coincided
`with the end of the antigen/antibody binding incubation). After
`the incubations, 75 µ.I (106) Fe-blocked HL60 cells were added
`to each microtiter well. The plate was incubated for 60 min at
`4°C. The contents of the microtiter wells were then transferred
`to appropriately labeled tubes. All tubes were washed with PBA
`twice, and 25 µI FlTC-labeled gam-lgM were added to each cell
`pellet and incubated in the dark for 30 to 40 min at 4°C. After
`washing, the cell pellets were resuspended in 0.5 ml I %
`parafonnaldehyde and allowed t o fix in the dark at 4°C for 1 h.
`Samples were analyzed by flow cytometry using histogram
`overlays with appropriate controls. Standards curves of r2 2:
`0.98 were used for detennining the amount of soluble CD15 in
`patient serum.
`Patients who were in first remission greater than I year and
`then relapsed were treated with 1-(3-o-arabinofuranosylcytosine
`(100 mg/m2/day) i.v. for 7 days and daunorubicin (45 mg/m2/
`day) i.v. for 3 days as an induction regimen. Patients who
`relapsed in less than I year or were in second or third relapse
`received high-dose 1-(3-o-arabinofuranosylcytoside (3 g/m2
`every 12 h) i.v. for 12 doses unless they bad prior treatment with
`this regimen. Etoposide (100 mg/m2/day) given i.v. for 5 days
`and mitoxantrone (10 mg/m2/day) given i.v. for 5 days were
`
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`

`Clinical Cancer Research %7
`
`used in patients who had already been treated with prior regi­
`mens listed.
`
`of Total CDIS-positive CeUs and Cell­
`Detennination
`bound MDX-11
`Total percentage of positive CD15 cells was detennined by
`indirect staining for CD15 on the patient cells using MDX-I I
`and a secondary FITC-labeled antibody. Cell-bound MDX-I I
`was detennined by using the secondary antibody to directly
`stain for MDX-11 already bound to the cell surface. Blood
`samples for detennination of total CD15-positive cells and
`cell-bound MDX-11 were taken from the patients at screening
`(bone marrow), before, during, and after infusion. In addition, a
`bone marrow sample was taken for determination of cell-bound
`MDX-11 at the tennination of the infusion. Leukemic cells were
`isolated by Ficoll-Hypaque gradient centrifugation within 12 h
`of collection. Separated cells were kept in RPMI 1640 on ice
`until ready for use. Prior to assay cells were washed with cold
`PBA and resuspended to 2 X 107/ml in PBA. Each assay tube
`received 106 (50 µI) cells. For detennination of total CD15-
`positive cells, cells were blocked with 25 µI human lgG (10
`mg/mJ) for 15 min on ice. Autofluorescence control tubes re­
`ceived 25 µI PBA, negative control tubes received 25 µI irrel­
`evant lgM, positive control tubes received 25 µI W632 super­
`natant (anti-HLA), and test tubes (assayed in duplicate) received
`25 µI MDX-11 (200 µg/ml). Cells were incubated with the
`primary antibody for 60 min on ice and washed. For cell-bound
`MDX-11 detennination and after washing following incubation
`of primary antibody for total CD15-positive cells, 50 µI PBA
`were added to autofluorescence tubes, and 50 µI of F(ab')i
`gam-lgG + lgM (H + L) FITC-labeled were added to the
`remaining tubes and incubated for 30 min on ice (dark). Cells
`were washed, resuspended in 1.0 ml 1 % parafonnaldehyde,
`stored in the dark at 4 °C, and allowed to fix for I h before
`analysis by flow cytometry. For cell-bound MDX-I I determi­
`nation, staining with FITC-labeled secondary antibody occurred
`simultaneously with the incubation of the primary antibody for
`total CD15-positive cells. The negative control used for calcu­
`lating cell-bound MDX-11 was the highest of either the t = 0
`cell-bound MDX-11 or the autofluorescence tube prepared for
`that time point.
`
`HAMA Detennination
`Human antimouse antibodies were assayed using a sand­
`wich ELISA in which the plate was coated with MDX-1 L
`Patient serum was incubated as the intennediate step and goat
`antihuman lgG alkaline phosphatase was the final antibody.
`Briefly, the plates were coated overnight at 4°C with 1 µg/well
`of MDX-11. After washing, the plate was blocked with 5% PBA
`for I to 2 h at 37°C and washed. Patient sera and NHS (negative
`control) were diluted in duplicate 1:20, 1:40, 1:80, and 1:160
`using 1 % PBA. Positive control serum from an individual who
`exhibited a HAMA
`titer of 1:240 (after repeated treatment with
`a bispecific antibody consisting of PM-81 and an anti-Fe recep­
`tor antibody) was diluted to 1:20-1:480. One hundred ml of all
`dilutions were added to the plates; blank wells received 100 µI
`l % PBA. The plate was incubated for 1.5 h at 37°C and washed.
`A working dilution of goat antihuman lgG alkaline phosphatase
`
`was added to all wells and incubated for 1.5 h at 37°C. After
`washing, the substrate was added and allowed to develop for 20
`min at room temperature. The reaction was stopped with l N
`NaOH, and the plate was read at 405 nm within 20 min.
`
`Flow Cytometry
`Flow cytometry was performed using a Becton Dickinson
`FACScan with Lysis II software. For acquiring antibody-stained
`leukemia cells from patients, forward scatter and side scatter
`settings were standardized with fixed, FITC-labeled HL60 cells,
`and fluorescence settings were standardized using a standard
`bead mixture. Both HL60 cells and the standard bead mixture
`were provided by Medarex, Inc. Typically, 10,000 cells were
`acquired for each sample. AJI on-site analyses were monitored
`by Medarex, Inc., for consistency.
`
`Stu dy Design
`Patients of any French-American­
`Patient Eligibility.
`British subclass of relapsed AML and secondary AML after a
`myelodysplastic phase or prior cytotoxic drug therapy were
`eligible. Age eligibility included patients 18 years or older.
`Kamofsky perfonnance status was required to be >70%. Leu­
`kemic blast cells were required to be >20% positive for MDX­
`I I. The criteria for cardiopulmonary, liver, and renal function
`were delineated as left ventricular ejection fraction >0.4, forced
`expiratory volume (one second) >70% predicted, hepatic
`transaminases < three times normal values,
`
`and creatinine clear­
`ance >50 ml/h.
`Patients were hydrated with nor­
`mAb Administration.
`mal saline for 4 h prior to administration of MDX-11 to increase
`intravascular volume in hopes of minimizing allergic reactions
`and/or toxicities. Patients were also premedicated with diphen­
`hydramine and acetaminophen. The mAb was administered i.v.
`through either a peripheral or central line. Three patients re­
`ceived doses of 0.5 mg/kg, 8 patients received LO mg/kg, and 5
`patients received L5 mg/kg. The infusion rate was 10 ml/h (240
`ml/24 h). Patients received conventional chemotherapy imme­
`diately following completion of the MDX-11 infusion.
`Tests Perfonned. Before and during the MDX-11 infu­
`sion, complete blood counts and electrolytes were perfonned.
`Serum complement, lactate dehydrogenase with isoenzymes,
`and uric acid levels were checked before, during, and after
`infusion. Phannacokinetic parameters included complete blood
`counts with differential and platelet counts, cell-bound MDX­
`I I, total CD15-positivecells, serum CD15, and serum MDX-11.
`These parameters were studied before, during, and after
`MDX-11 infusion. Bone marrow aspirates were obtained for
`cytology, and flow cytometry assays were obtained at patient
`screening and at the end of the mAb infusion (24 h). Complete
`blood counts were performed weekly for 12 weeks after infu­
`sion. Physical examination, performance status, serum chemis­
`try, serum electrolytes, routine urinalysis, and PT/PTT were
`done at 4, 8, and 12 weeks after MDX-I I infusion. HAMA
`assays were done at 2, 4, 8, and 12 weeks after infusion.
`Toxicity during and after the
`Toxicity Measurements.
`infusion was assessed and graded according to the Eastern
`Cooperative Oncology Group (ECOG) toxicity grading scale.
`
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`

`968 Phase I Clinical Trial of Scrotherapy in Patients with AML
`
`Table I
`Patient characteristics
`
`Patient
`
`Agefscx
`
`Diagnosis
`
`IO I
`I02
`103
`104
`105
`106
`107
`108
`109
`110
`301
`302
`303
`304
`401
`402
`
`241M
`38/F
`671M
`621M
`26/F
`561M
`221M
`611M
`521M
`60/F
`24/F
`371M
`271M
`46/M
`481M
`67/M
`
`AML
`AML
`AML
`AML
`AML
`MDS0 converted to AML
`AML (secondary to Hodgkin's disease)
`MOS converted to AML
`AML
`AML
`AML
`AML
`AML
`MOS converted to AML
`AML
`AML
`
`a MDS. myelodysplastic synd rome.
`
`Initial blood cell counts
`
`No. of
`relapses
`
`WBC
`(X 1000 )
`
`% Blast
`
`Hemoglobin P
`
`I
`4
`2
`I
`2
`0
`0
`0
`I
`3
`4
`I
`I
`0
`3
`2
`
`27.2
`22.6
`1.3
`66
`1.7
`9.2
`21.9
`7.8
`16.3
`0.4
`9.4
`2.9
`10.6
`73.t
`6.9
`3.4
`
`21
`98
`34
`5
`4
`84
`75
`13
`24
`24
`83
`0
`0
`84
`36
`5
`
`9.5
`8.4
`9.9
`JO.I
`8.7
`8.4
`9.3
`7.6
`8.6
`9.6
`12.1
`10.9
`12
`8.5
`9.9
`10.5
`
`RESULTS
`With the exception of HAMA results, the following results
`and discussion are based on data obtained before infusion of
`MDX-11, during infusion of MDX-I I, and immediately after
`the infusion (infusion end, t = 24) prior to receiving chemo­
`therapy. Thus, decreases in cell counts and pharmacokinetics
`results are due to the effects of MDX-11 immunotherapy and
`not the subsequent chemotherapy.
`
`Patients
`Sixteen patients between the ages of 22 and 67 (median
`age, 47) years were treated in this Phase I study. Each had a
`Kamofsky status >80%, and all met the criteria for leukemic
`blast cells >20% positive for MDX-I I. Exceptions for cardio­
`pulmonary status were made for two patients who had pulmo­
`nary function test results that were suboptimal or had decreased
`left ventricular function. Table 1 lists individual patient charac­
`teristics.
`
`Toxicity
`Thirteen patients received the intended dose of MDX-11.
`Three patients (patients 104, 303, and 401) experienced serious
`reactions necessitating termination of the infusion. Another pa­
`tient (patient 106) experienced milder reactions necessitating
`infusion delays that resulted in the complete infusion taking
`33.S h rather than the intended 24 h. Patient 109 also experi­
`enced minor problems leading to interuption of the infusion for
`45 min. This patient's results were still included in the pharma­
`cokinetic analyses. Pharmacokinetic data for other patients are
`incomplete due to insufficient numbers of cells for analysis. The
`majority of toxicities were common side effects experienced
`during mAb infusions or minor allergic reactions that resolved
`upon treatment (fable 2).
`All three patients treated at the 0.5-mg/kg level tolerated
`the MDX-11 infusion without experiencing adverse reactions
`to the mAb. Of the eight patients treated at the l .0 mg/kg
`level, four completed the MDX-I I infusion with no adverse
`
`reactions. Two reported adverse reactions of mild fever and
`mild hypotension, National Cancer Institute toxicity grade 2.
`One patient (patient 109) experienced hypotension and re­
`ported dizziness, nausea, vomiting, back pain, aching, short­
`ness of breath, and fever. The mAb infusion was stopped, and
`the patient was treated for the symptoms and infused with
`normal saline. The mAb infusion was restarted after the
`symptoms subsided (approximately 45 min). The adverse
`events were considered to be mild (ECOG grade II or less).
`The eighth patient (patient 104) treated at the 1.0-mg/kg level
`experienced an acute respiratory episode and reported nau­
`sea, vomiting, dizziness, and fever. The infusion was stopped
`after 20 min, and the symptoms resolved within 3 h after
`treatment. Although the adverse events were grade II or less,
`the infusion was not restarted.
`Three of the five patients receiving 1.5 mg/kg MDX-I I
`completed the infusion. One reported no adverse events re­
`lated to the infusion. Two patients experienced grade II
`(ECOG) events. One of these patients (patient 401) experi­
`enced hypotension, chest pain, diaphoresis, and nausea. The
`infusion was stopped and not restarted. The symptoms re­
`solved upon treatment. The second patient with grade II
`toxicities experienced hypotension, fever, chills, sinus con­
`gestion, and sneezing. Two of the patients treated at 1.5
`mg/kg experienced grade IV (ECOG) events. One patient
`(patient !OS) reported fatigue, chills, hypotension, fever,
`respiratory distress, and tachycardia, but completed the
`MDX-I I infusion. This patient died 4 days after infusion due
`to an underlying Gram-negative sepsis (Escherichia coli).
`The second patient (patient 303) with a grade IV event
`experienced severe back pain, facial burning, shortness of
`breath, and nausea 7 min into the infusion. The infusion was
`halted, and the patient subsequently developed tachycardia,
`fever, disseminated intravascular coagulation, rhabdomyoly­
`sis, and respiratory distress. These symptoms all resolved
`upon treatment. The infusion was not restarted.
`
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`Clinical Cancer Research 969
`
`Table 2 Toxicities experienced by patients during PM-81 infusion•
`
`Severity
`
`Relation to MDX-I I
`
`Patient
`Dose
`Mild
`Symptom
`count
`(mg/kg)
`0.5 Headache
`1/3
`0
`Chest pain
`0
`1/3
`Nausea
`0
`1/3
`I
`1/3
`Rash
`I
`1.0 Oyspnea
`318
`Chills
`1
`218
`Hypotension
`0
`218
`Nausea
`0
`218
`Vomiting
`2
`218
`0
`Bronchospasm
`118
`I
`Asthenia
`118
`I
`Headache
`118
`Back pain
`0
`118
`Vasodilation
`0
`118
`I
`Hypoxia
`118
`Pruritus
`2
`218
`I
`Fever
`218
`Tachycardia
`0
`118
`I
`Myalgia
`118
`1.5 Fever
`0
`4/5
`I
`Nausea
`315
`Chest pain
`0
`215
`Tachycardia
`0
`215
`Oyspnea
`0
`215
`0
`Back pain
`115
`Vasodilation
`0
`1/5
`Hypoxia
`0
`1/5
`Bilirubinemia
`0
`115
`Myopathy
`0
`115
`Pruritus
`0
`1/5
`Hypotension
`0
`315
`Chills
`0
`215
`I
`Asthenia
`1/5
`Blood pressure instability
`0
`1/5
`•Toxicities listed in order of dose and probable relation to MDX-1 I.
`
`Moderate
`I
`I
`I
`0
`I
`I
`2
`2
`0
`0
`0
`0
`I
`I
`0
`0
`1
`I
`0
`4
`2
`2
`2
`2
`0
`I
`0
`0
`0
`I
`2
`2
`0
`0
`
`Severe
`0
`0
`0
`0
`I
`0
`0
`0
`0
`I
`0
`0
`0
`0
`0
`0
`0
`0
`0
`0
`0
`0
`0
`0
`I
`0
`I
`I
`I
`0
`l
`0
`0
`I
`
`Possible
`I
`I
`I
`I
`2
`0
`0
`I
`I
`0
`0
`0
`0
`0
`0
`I
`2
`I
`I
`2
`2
`0
`I
`I
`0
`0
`0
`0
`0
`0
`l
`2
`I
`I
`
`Probable
`0
`0
`0
`0
`0
`1
`I
`0
`0
`0
`0
`0
`0
`0
`0
`I
`0
`0
`0
`I
`0
`I
`0
`0
`0
`0
`0
`0
`0
`0
`2
`0
`0
`0
`
`Highly
`probable
`0
`0
`0
`0
`I
`I
`I
`I
`I
`I
`I
`I
`I
`I
`I
`0
`0
`0
`0
`I
`I
`I
`I
`I
`I
`1
`I
`I
`I
`l
`0
`0
`0
`0
`
`TableJ Patient blast counts (X 1000) before MOX-I I infusion,
`during infusion, at infusion end, and after infusion during
`chemotherapy
`
`HAMAs
`Only one patient developed HAMAs noted 4 weeks after
`
`
`infusion (titer, 60). This patient was treated with the 0.5-mg/kg
`dose of MDX-11.
`Infusion stan
`Infusion end
`HAMA
`assays for lgM and lgE (along with the usual assay
`r = 0 I = 12 h
`r = 24 h
`Patient
`for HAMA
`lgG) were perfonned on all three patients
`who
`5.71 2.09 10.91
`101
`
`
`experienced severe adverse reactions. Titres for all three patients
`102 22.15 1.25 8.46
`were within the nonnal range as compared to pooled human
`103 0.44 0.14 0.41
`
`sera and 1-week postinfusion sera from the
`sera. The screening
`0.07 0.00
`105
`O.ot
`3.04
`107 16.43 ND"
`
`
`patient experiencing the most severe reaction were also tested
`I.OJ
`ND
`108
`0.00
`
`for elevated levels of lgE antibody but were found to be within
`3.91 3.61 1.37
`109
`nonnal ranges.
`0.10 0.00
`0.00
`110
`301
`7.80 12.32 11.19
`302
`0.00
`0.00
`0.00
`304 70.18 93.12 65.14
`0.00
`0.09
`402
`0.00
`• NO, not done.
`
`Postchemotherapy
`stan
`I = 48 h
`2.34
`33.25
`0.40
`0.02
`4.06
`1.17
`1.15
`0.00
`9.49
`0.00
`33.07
`0.06
`
`Effect of Infusion on WBC and Blast Counts
`Nine (75%) of 12 patients
`had a decrease in total WBC
`
`
`Seven of the count at the completion of the MDX-11 infusion.
`WBCs had a 50% or greater tran­
`
`nine patients with decreased
`
`sient decrease in their WBC. Blast counts at the infusion end
`for 8 (67%) of the 12 patients,
`decreased
`with as many patients
`Pharmacokinetics
`
`experiencing a 50% or greater transient
`decrease in their blast
`counts (Table 3). Significant
`
`transient decreases of WBCs and
`blast counts were seen at all three MDX-11 doses.
`
`Serum MDX·ll Levels. The dose of MDX-11 received,
`
`
`
`along with lhe initial reservoir of CD15, whether cell-bound (on
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`
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`
`on August 31, 2015. © 1995 American Association for Cancer
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`

`970 Phase I Clinical Trial of Serotherapy in Patients with AML
`
`Table4 PM-81 dose vs. maximum scrum PM-81 levels achieved during infusion and initial (1 = 0) c ell counts (X IOOO/ ml)
`Max imum scrum
`Initial
`PM-81 (µg/ml)
`WBC
`
`Patient
`
`Dosage
`(mg/kg}
`
`Initial
`blast count
`
`%CDl5·
`positive blasts
`
`105
`107
`l IO
`402
`301
`302
`108
`109
`304
`1()3
`I02
`IOI
`" ND, not done.
`
`1.5
`1.5
`1.0
`1.0
`1.0
`1.0
`1.0
`1.0
`1.0
`0.5
`0.5
`0.5
`
`3.56
`1.46
`4.76
`1.06
`1.02
`0.75
`<0.50
`<0.50
`<0.50
`0.00
`0.00
`0.00
`
`1.7
`21.9
`0.4
`3.4
`9.4
`2.9
`7.8
`16.3
`73.l
`1.3
`22.6
`27.2
`
`0.1
`16.4
`0.1
`0.0
`7.8
`0.0
`1.0
`3.9
`70.2
`0.4
`22.2
`5.7
`
`93
`100
`64
`64
`29
`99
`89
`82
`ND"
`87
`100
`45
`
`Initial CDl5·
`positive blasts
`0.1
`16.4
`0.1
`0.0
`2.3
`0.0
`0.9
`3.2
`ND
`0.4
`22.2
`2.6
`
`Table 5 Serum CD15 and serum PM-81 levels vs. percentage of leukemic bone marrow blasts with cell-bound PM-81 at infus ion end (t = 24)"
`Serum CDl5
`Serum PM-81
`(mg/ml}
`(µg/ml)
`
`I= 24
`I = 0
`I= 0
`Patient
`0.24
`105
`0
`0.00
`0.59
`0
`0.00
`107
`0
`0.00
`0.13
`110
`0
`402
`0.00
`0.38
`0.71
`301
`0
`0.00
`302
`0.59
`0
`0.00
`0
`0.00
`0.99
`108
`109
`0.12
`0
`1.26
`0
`0.00
`0.10
`304
`1.24
`0.59
`IOI
`0
`102
`0
`0.00
`0.30
`0
`0.00
`0.27
`103
`" Pooled human se ra control averaged 0.32 mg/ml serum CDIS.
`b ND, not done.
`
`I= 24
`
`2.10
`J.46
`4.76
`1.06
`1.02
`0.00
`<0.50
`0.00
`<0.50
`0.00
`0.00
`0.00
`
`Maximum serum
`PM-81
`
`3.56
`1.46
`4.76
`1.06
`1.02
`0.75
`<0.50
`<0.50
`<0.50
`0.00
`0.00
`0.00
`
`24-h bone marrow
`% Pos. PM-81
`65
`64
`60
`16
`ND
`ND
`16
`II
`ND
`ND
`0
`0
`
`normal or leukemic cells) or soluble, affected the serum levels
`of MDX-11. Patients receiving the lowest dose of MDX-11 (0.5
`mg/kg) had no detectable serum mAb, while all patients receiv­
`ing the highest dose (l.5 mg/kg) had quantifiable serum MDX-
`1 l. Patients receiving the median dose (1.0 mg/kg) had detect·
`able serum MDX-11 levels (Table 4). Serum MDX-I I levels
`typically peaked between 12 and 24 h and returned to 0 within
`24 h after the infusion.
`The amount of MDX-I I present in sera tended lo be
`highest in patients who received the higher doses and had the
`lower initial reservoir of cell-bound CDIS (lower initial WBC
`or tumor burden). Conversely, patients who received lower
`doses of the antibody, and/or had higher reservoirs of cell-bound
`CDIS, had little to no MDX·l l present in their serum, unless
`there was a high percentage of blasts with low CDlS expression,
`as in patient 301 (Table 4).
`Soluble CD15 levels were also related to the serum
`MDX-I I levels; in general, patients with the lowest levels of
`serum CD15 al t = 0 for their dosage achieved the highest
`serum levels of MDX-11 [with the exception of patient 304
`whose initial cell-bound CD15 (WBC and blast counts) were
`significantly higher than the other patients; Tables 4 and 5). As
`expected, patients had either free antibody or free antigen
`
`present in their serum at t = 0 and t = 24; in no case did we find
`both serum MDX-I I and serum C015 present simultaneously.
`Patients 101 and 109 were the only patients to have serum CDIS
`still present at t = 24 (Table 5). Note that patient I 0 l received
`the lowest dose of MDX·ll, had the second highest initial
`WBC, and never achieved detectable levels of serum MDX-I l ,
`whereas patient 109 had a very high initial serum CD15 level
`and also did not have detectable serum MDX-11. Thus, the
`initial reservoir of CD15, whether cell-bound (on normal or
`leukemic cells) or soluble, was important in determining a patient's
`ability to achieve serum levels of MDX-11. Serum levels of COJS
`were unrelated to the patient's initial WBC or blasts counts.
`Cell-bound MDX-11. Cell-bound MDX-11 on circulat·
`ing blasts was followed throughout the duration of the infusion,
`and a bone marrow biopsy was obtained at the infusion end (t =
`24 h). Serum levels of MDX-11 correlated with the amount of
`MDX-11 reaching the leukemic blasts in marrow (Table 5).
`Those patients who had no detectable serum MDX· I I levels had
`no detectable cell-bound MDX-I I in their marrows, while those
`patients with serum levels of MOX-I l had cell-bound MDX-11
`on their marrow blasts.
`The percentage of peripheral leukemic blasts with cell­
`bound MDX-11 was also an indicator of cell-bound MDX-11 in
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`Clinical Cancer Research 971
`
`bound by MDX-I I in those patients achiev­
`
`clearly completely
`marrow leukemic blasts. Those patients who had both quantifi­
`
`
`
`ing detectable serum levels of the mAb, it seems the reasons for
`able serum levels of MDX-I I and >50% circulating blasts with
`
`
`unbound antigen on cell surface are not due to problems of
`
`cell-bound MDX-I I had 2:60% leukemic blasts in their marrow
`
`
`antigen/antibody interactions or lack of MDX-11, but more
`
`
`
`with cell-bound MDX-I I. Patients with lower percentages of
`
`
`
`
`likely to distribution and production of blasts. Further studies to
`
`
`