Pulse Infusion Interleukin-2 with Famotidine and Cyclophosphamide Has Activity in Previously Treated Metastatic Melanoma

Abstract

There is no established systemic therapy for patients with stage IV melanoma refractory to prior systemic treatment. Interleukin-2 (IL-2) is capable of inducing T-lymphocyte cytotoxicity against melanoma in vitro and in vivo. Famotidine may enhance the activity of T-cells further by allowing for increased IL-2 internalization by the IL-2 receptor on lymphocytes. Cyclophosphamide may decrease the immunosuppressive effects of regulatory T-cells. Daily short intravenous (i.v.) infusions (pulses) of IL-2 were used to treat 14 patients with metastatic melanoma, all of whom had experienced disease progression despite prior systemic therapy. The patients received 21.6 million IU/m² of pulse IL-2 i.v. for 15–30 minutes, preceded by 20 mg of famotidine i.v. (13) patients received 350 mg/m² of cyclophosphamide i.v. on day 1 (1 patient did not). Eight (8) patients were treated in an oncology inpatient unit while, most recently, 6 patients have received therapy on an outpatient basis. The cycles were repeated every 3 weeks until disease progression occurred. The patients included 10 males with a median age of 56 (range 31–87) with an Eastern Cooperative Oncology Group performance status of −1 (range 0 – −1). Common metastatice sites included lymph nodes (13), lungs (8), liver (4), and subcutaneous (4). Prior systemic therapy included IL-2 (11), interferon (7), and chemotherapy (7). The median number of cycles the patients underwent was 3 with a range of 1–7. The most common toxic reactions were fever, rigors, nausea/emesis, hypomagnesemia, and hypophosphatemia. One complete response and four partial responses were observed (response rate, 36%; 95% confidence interval: 14%–64%). Responses occurred in the lungs, liver, lymph nodes, and subcutaneous sites. The median response duration was 3.4 months, with a median survival of 8.3 months for the entire group. Six (6) patients remain alive with a median survival of 10.3 months. Pulse IL-2 with famotidine and cyclophosphamide produced activity in previously treated patients with melanoma and may be given on an outpatient basis to selected individuals.

Introduction

Metastatic melanoma is typically resistant to cytotoxic chemotherapy.¹ In addition, there is no established second-line therapy for metastatic disease. Single immunotherapy agents, including newer agents such as the anti-CTLA-4 monoclonal antibodies ipilimumab and tremelimumab, yield response rates of less than 20%.^2,3

Interleukin-2 (IL-2) is capable of eliciting antitumor effects against melanoma cells in vitro and in patients with metastatic melanoma.^4

–7 Lymphocytes, either cytotoxic T-cells or activated natural killer (NK) cells, are the primary mediators of these actions.^4
–6,8 High-dose IL-2 given via a thrice-daily dosing schedule yields response rates of ∼16%–17%, with complete response rates of approximately 6%–7%.^7,9

The clinical use of this cytokine, however, is limited by its toxicity, including a capillary leak syndrome manifested by fluid retention, hypotension, decreased organ perfusion, and, at times, pulmonary edema.^9
–11 Approximately 45%–74% of patients on high-dose, thrice-daily bolus IL-2 protocols may require vasopressors to support their systemic blood pressure (BP).

Daily short infusions (or pulses) of IL-2 at doses of 18–21.6 million international units (MIU)/m² have been developed in an attempt to decrease IL-2's toxicity while maintaining its anticancer activity. Response rates of 15%–26% have been reported in kidney cancer and melanoma.^12,13

Mitchell et al. combined low-dose cyclophosphamide with IL-2 to preferentially diminish the effect of regulatory T-cells that may dampen an antitumor immune response.¹² The combination of pulse-dose IL-2 and cyclophosphamide has been shown to elicit T-cells with cytotoxicity patterns against melanoma, similar to those described previously with vaccine therapy.^14
–16

Famotidine enhances the ability of lymphocytes including T-cells to kill tumor cell lines in vitro, presumably by increasing IL-2 uptake by lymphocytes.¹⁷ Tsunoda et al. reported that the serum level of famotidine required for this effect is achievable clinically.¹⁷

Previously, continuous infusion IL-2 at 9 MIU/m²/day were used for 3 days, preceded by cyclophosphamide on day 1, and this cycle was repeated every 3 weeks. A partial response was observed in 7 patients with previously treated melanoma.¹⁸

This article describes the experience of a group of patients treated with a combination of low-dose cyclophosphamide, pulse IL-2 (21.6 MIU/m²/day), and famotidine in terms of response rate, median duration of response, and median survival in patients with metastatic melanoma who have progressed on at least one prior systemic therapy.

Patients and Methods

Fourteen (14) patients (10 men and 4 women; median age 56, range: 31–87) with measurable evidence of histologically confirmed metastatic melanoma were treated. All of them had experienced progressive disease despite prior systemic therapy. These patients' characteristics are listed in detail in Table 1. As with the earlier regimens for melanoma, these patients were required to have an Eastern Cooperative Oncology Group performance status 0 or 1; an estimated survival of at least 3 months; a white blood cell (WBC) count >3500/mm³; platelets >100,000/mm³; hemoglobin >9.0 g/dL; total bilirubin, alanine transaminase (ALT), and aspartate aminotransferase (AST) <3 times the upper limit of normal; and serum creatinine <2.0 mg/dL.^19,20 Patients with autoimmune diseases, such as inflammatory arthritis which could potentially be exacerbated by IL-2; any medical illness requiring corticosteroids or other immunosuppressive agents such as methotrexate; current untreated brain metastases; or history of significant cardiovascular disease (CVD) including myocardial infarction, congestive heart failure, primary cardiac arrhythmias, angina pectoris, or cerebrovascular accident, were excluded from the study. Informed consent was obtained from all patients prior to the study.

Table 1.

Patient Characteristics

Male/female	10/4
Median age (range)	56 (31–87)
Performance status (median)	1 (0–1)
Most common sites of disease
Lymph nodes	13 (93%)
Lung	8 (57%)
Liver	4 (29%)
Subcutaneous	4 (29%)
M1a	3 (21%)
M1b	5 (36%)
M1c	6 (43%)
Prior systemic therapy for metastatic disease
Interleukin-2	11 (79%)
Interferon	7 (50%)
Chemotherapy	7 (50%)
Anti-CTLA4	1 (7%)
Median number of cycles received (range)	3 (1–7)

Prior to treatment on this regimen, all patients had to undergo a low-level cardiac stress test and/or cardiac evaluation to exclude occult atherosclerotic heart disease.

A complete history was taken for each patient who was included in the study, and all patients underwent a physical examination that included acomplete blood count (CBC) with differential, a hepatic profile, serum creatinine, chest X-ray, tumor measurements, and evaluation of performance status. Blood studies including CBC, liver enzymes, electrolytes, and creatinine were obtained daily prior to IL-2 therapy. Radiographic studies to evaluate the response were performed after every two cycles. Standard Response Evaluation in Solid Tumors (RECIST) response criteria were used.²¹ Partial responses were measured from the date the responses were determined by tumor measurements.

Treatment regimen

All 14 patients received 20 mg of famotidine intravenously (i.v.), followed by 18 MIU/m²/day of IL-2 in 50 cc of 5% dextrose i.v. over 15–30 minutes on days 1–5. Thirteen (13) patients received 350 mg/m² of cyclophosphamide i.v. on day 1 (1 patient did not). Treatment cycles were repeated every 3 weeks for four cycles, then every 3–4 weeks for two cycles, then every 4–6 weeks, in the absence of disease progression or intolerable toxicity.

Supportive care

Therapy was administered by oncology trained nurses in an oncology inpatient unit (8 patients) or in an outpatient infusion center (6 patients). The patients were premedicated with 16–32 mg of ondansteron and 25 mg of meperidine i.v., and 650 mg of acetaminophen and 400 mg of ibuprofen orally. The patients were examined daily to determine their tolerance to therapy. Those with systolic BP (SBP) <90 mm Hg were treated with normal saline infusions and, if needed, with dopamine, typically starting at 5 mcg/kg/minute and titrated to keep the SBP >90 mm Hg. Patients with serum creatinine >2.1 mg/dL or urine output <250 cc/12 hours received 1 mcg/kg/minute of dopamine for renal perfusion.¹⁹ Patients who experienced grade III toxicity that unresponsive to standard measures had doses omitted.

The 6 patients in the outpatient unit received i.v. normal saline at 70 cc/hour as baseline maintenance fluids. The patients treated thus did not require dopamine to support their BP. As a result, these patients were able to be observed for approximately 5–6 hours after completion of their IL-2 infusions and then discharged to go home. They then returned for the next scheduled day of therapy. Otherwise, their therapy was identical to that of the patients in the inpatient unit.

Results

A total of 44 treatment cycles were administered, with the median number of cycles received by each patient being 3 (range: 1–7). Overall, this treatment regimen was well-tolerated, although the patients experienced some toxic reactions, most commonly fever, rigors, nausea/emesis, hypomagnesemia, and hypophosphatemia (Table 2). Ninety-eight percent (98%) of the planned pulses were administered. The most common causes for doses being omitted are listed in Table 3.

Table 2.

Most Common Toxic Reactions

Reaction	No.	% of patients
Rigors	13	93
Fever	12	86
Nausea/emesis	12	86
Hypomagnesemia	8	57
Hypophosphatemia	8	57
Low serum bicarbonate	8	57
Hypokalemia	7	50
Thrombocytopenia	6	43
Hypotension	6	43
Arthralgia/myalgia	5	36
Elevated creatinine	5	36
Elevated LFTs	5	36

LFTs, liver function tests.

Table 3.

Most Common Causes of Dose Omission

Toxic reaction	No.
Elevated bilirubin	4
Patient declined	3
Venous access	1

Six (6) patients developed hypotension. Three (3) required transient use of dopamine at 5 mcg/kg/minute to keep their SBP >90 mm Hg. All three incidents occurred early in accrual prior to our use of daily maintenance IV fluids.

However, none of the 6 patients who received daily i.v. fluids for hydration required dopamine. These patients spent only a total of 8 hours (approximately 5–6 hours after completion of IL-2) in our outpatient infusion center. None of them required hospitalization for management of toxicity related to therapy.

Two (2) patients with bone metastases required transfusions of packed red blood cells.

All of the toxicities above have been described with IL-2-based therapies.

Response to therapy

Responding patients are described in Table 4. One (1) patient with a lymph node–based disease had a complete response to therapy (complete response rate, 7%; 95% confidence interval [CI]: 0.37%–36%). Four (4) patients showed partial responses (29%; 95% CI: 9.6%–58%). The overall response rate then was 36% (95% CI: 14%–64%).

Table 4.

Response to Therapy

Disease site	Response	Duration (months)
Liver	Partial	2+
Lymph nodes	Complete	5.6
Liver, lungs, lymph nodes, subcutaneous	Partial	1
Lungs, lymph nodes, soft tissue	Partial	3.5
Liver, lungs, lymph nodes	Partial	3.3

The median survival of all patients was 8.3 months. Responding patients had a median survival of 12.8 months. The median survival of nonresponders was 7.3 months. Six (6) patients are alive as of this writing at a median of 10.3 months.

Discussion

As of late 2009, dacarbazine and IL-2 are the only two agents indicated by the Food and Drug Administration for treatment of metastatic melanoma. The refractory nature of this cancer has been particularly problematic in the second-line setting, with typical response rates being less than 10% with chemotherapy agents alone or in combination, or with single biologic agents.^2,3,22,23

An exception to this appears to be IL-2–based therapy. Both Weinrich and Rosenberg and Tarhini et al. have described response rates of 13%–19% in inpatients receiving second-line high-dose IL-2.^24,25 The difficulty of administration secondary to toxicity of this regimen, however, often limits its applicability in older patients.^9
–11

Mitchell et al. demonstrated the safety and activity of combining single daily i.v. doses of IL-2 with low-dose cyclophosphamide.^12,14 This 21.6 MIU/m² of IL-2 dose, which has been referred to in this article as a pulse dose, was given for 5 days for 2 consecutive weeks. Patients on this schedule received 350 mg/m² of cyclophosphamide i.v. 3 days prior to the first IL-2 dose and then approximately every 3 weeks. The rationale for the low dose of this agent was that regulatory T-cells that dampen an antitumor immune response could be preferentially diminished by cyclophosphamide. This regimen has been shown to elicit T-cell cytoxicity against melanoma cell lines in vitro.¹⁴

Complete responses were seen in 5% and partial responses in 21% of the treated patients in that study. The combination was well-tolerated with no treatment-related deaths or intensive care admissions. Other researcherss have examined this combination but have found less activity than in the original study above.^26
–28

The 36% response rate in the cohort of patients in the present study is encouraging, considering that all patients had had disease progression with prior therapy. Of note, in the present study, there were responses in metastases involving the liver, which is historically an unresponsive site to systemic therapy. This is similar to the observation of Mitchell et al., who reported 4 responses in 10 patients with liver metastases on using IL-2 and cyclophosphamide.¹²

With the three-drug combination used in the present study, responses were obtained with less IL-2 than in the studies using IL-2 and cyclophosphamide alone. Whether this reflects the possible enhancement of T-cell cytotoxicity by famotidine is not known. Famotidine, unlike the related antihistamine cimetidine, has not been tested as a single agent in melanoma.²⁹

Prior IL-2 exposure did not seem to limit the activity of this regimen. Earlier studies by the National Biotherapy Study Group and the National Cancer Institute Surgical Branch using a combination of ex vivo–cultured T-cells and IL-2 have reported occasional complete responses in patients who had previously failed on other IL-2 regimens.^30
–32 It could be hypothesized that the use of an IL-2 and cyclophosphamide regimen, previously shown to elicit T-cells with cytotoxicity against melanoma, might be active in selected individuals as well.¹⁴ In the present study there are no in-vitro T-cell cytotoxicity assays to confirm this in the patients treated patients, however.

Finally, a longer term of survival is an important aspect of IL-2–-based therapy. Forty-three percent (43%) of the patients on this regimen have survived at least 12 months. Previously, the present researchers reported that 25% of patients treated with continuous infusion IL-2 and famotidine survived 24 months or longer.³³ When analyzing survival data it is difficult to determine the contribution of the treatment regimen relative to other factors such as subsequent therapy and difference in the tumor biology of individual patients. The relatively small number of patients in the present study also limited subgroup analysis. Two (2) of these “long term” (>1 year survival) patients had stable disease on this therapy and were not counted among the responders. Three (3) patients have gone on to receive other IL-2–based therapy and experienced periods of stable disease, which may contribute to their survival.

Conclusions

Pulse IL-2 with famotidine and cyclophosphamide produces activity in previously treated patients with melanoma and may be given on an outpatient basis to selected individuals.

Footnotes

Disclosure Statement

No competing financial interests exist.

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