© 1999 by Oxford University Press
Journal of the National Cancer Institute, Vol. 91, No. 9, 763-771,
May 5, 1999
© 1999 Oxford University Press
Adenovirus-Mediated p53 Gene Transfer in Advanced Non-Small-Cell Lung Cancer
Affiliations of authors: S. G. Swisher, J. A. Roth, J. B. Putnam, Jr., G. L. Walsh (Section of Thoracic Molecular Oncology, Department of Thoracic and Cardiovascular Surgery), D. D. Lawrence, C. H. Carasco, W. R. Richli, M. K. A. Waugh (Department of Diagnostic Imaging), F. Fossella, B. S. Glisson, W. K. Hong, F. R. Khuri, J. M. Kurie, J. S. Lee, R. Perez-Soler, K. M. W. Pisters, D. M. Shin (Department of Thoracic/Head and Neck Medical Oncology), J. J. Lee (Department of Biomathematics), B. L. Kemp, A. K. El-Naggar (Department of Pathology), The University of Texas M. D. Anderson Cancer Center, Houston; J. Nemunaitis, PRN Research Inc., Baylor University Medical Center, Houston; D. G. Connors, J. A. Merritt, Introgen Therapeutics, Inc., Houston; M. Mack, M. Savin, A. Shulkin, J. Wait, D. Weill, Medical City Dallas Hospital, TX; D. M. Nguyen, D. S. Schrump, National Cancer Institute, Bethesda, MD; J. C. Nesbitt, C/V Associates, Nashville, TN.
Correspondence to: Stephen G. Swisher, M.D., Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 109, Houston, TX 77030.
 |
ABSTRACT |
|---|
 Top Abstract IntroductionPatients and MethodsResultsDiscussionReferences |
|---|
BACKGROUND: Preclinical studies in animal models have demonstrated tumor regression following intratumoral administration of an adenovirus vector containing wild-type p53 complementary DNA (Ad-p53). Therefore, in a phase I clinical trial, we administered Ad-p53 to 28 patients with non-small-cell lung cancer (NSCLC) whose cancers had progressed on conventional treatments. METHODS: Patients received up to six, monthly intratumoral injections of Ad-p53 by use of computed tomography-guided percutaneous fine-needle injection (23 patients) or bronchoscopy (five patients). The doses ranged from 106 plaque-forming units (PFU) to 1011 PFU. RESULTS: Polymerase chain reaction (PCR) analysis showed the presence of adenovirus vector DNA in 18 (86%) of 21 patients with evaluable posttreatment biopsy specimens; vector-specific p53 messenger RNA was detected by means of reverse transcription-PCR analysis in 12 (46%) of 26 patients. Apoptosis (programmed cell death) was demonstrated by increased terminal deoxynucleotide transferase-mediated biotin uridine triphosphate nick-end labeling (TUNEL) staining in posttreatment biopsy specimens from 11 patients. Vector-related toxicity was minimal (National Cancer Institute's Common Toxicity Criteria: grade 3 = one patient; grade 4 = no patients) in 84 courses of treatment, despite repeated injections (up to six) in 23 patients. Therapeutic activity in 25 evaluable patients included partial responses in two patients (8%) and disease stabilization (range, 2-14 months) in 16 patients (64%); the remaining seven patients (28%) exhibited disease progression. CONCLUSIONS: Repeated intratumoral injections of Ad-p53 appear to be well tolerated, result in transgene expression of wild-type p53, and seem to mediate antitumor activity in a subset of patients with advanced NSCLC.
|
INTRODUCTION |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
|---|
The p53 gene (also known as TP53) encodes a 593-amino acid phosphoprotein that plays a critical role in cell cycle regulation and control of apoptosis (1-3). p53 gene mutations have been associated with tumor progression and the development of chemotherapy and radiation therapy resistance (4-6). The development of gene transfer technology has allowed the transduction of cancer cells with wild-type p53 (wt-p53). Intratumoral injection of retroviral or adenoviral wt-p53 constructs in animal models results in tumor regression in a variety of different tumor histologies, including non-small-cell lung cancer (NSCLC), leukemia, glioblastoma, and breast, liver, ovarian, colon, and kidney cancers (7-13). Furthermore, Roth et al. (14) demonstrated the safety and feasibility of using a retroviral wt-p53 construct in patients with advanced NSCLC. In that trial, tumors regressed in three of seven evaluable patients after bronchoscopic or computed tomography (CT)-guided injection of retroviral wt-p53.
The clinical use of retrovirus vectors is limited, however, by difficulties in transducing nonreplicating cells and producing high titers of virus. Adenoviruses, on the other hand, are large, double-stranded DNA viruses with a tropism for lung cancer cells (15). Furthermore, they are capable of transducing nonreplicating cells and can be grown to high titers in vitro, which allows for their potential clinical utility (16). We, therefore, designed a phase I clinical trial using an adenovirus vector containing wt-p53 complementary DNA (cDNA) to treat patients with advanced NSCLC whose cancers had progressed on conventional treatments.
|
PATIENTS AND METHODS |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
|---|
Protocol approval. The protocol used was approved by the Biosafety and Surveillance Committees/Institutional Review Board of the participating institutions, the Recombinant DNA Advisory Committee of the National Institutes of Health, and the U.S. Food and Drug Administration (17).
Gene transfer vector. The construction and generation of Ad-p53 were reported previously (18). Briefly, E1-deleted replication-defective recombinant adenovirus was constructed with the use of a modified type 5 adenovirus genome. The cytomegalovirus (CMV) promoter was used to drive transcription of human wt-p53 cDNA. Ad-p53 was supplied by Introgen Therapeutics, Inc.
Eligibility criteria and treatment protocol. Patients with histologically proven
NSCLC were enrolled in the trial. All patients had unresectable tumors and either were unable to
receive primary external beam radiation therapy or had a recurrence after such therapy. Patients
were also eligible if they did not respond to or relapsed after chemotherapy. Patients had either an
endobronchial tumor that was accessible by the bronchoscope with some clinical evidence of
bronchial obstruction, advanced local-regional cancer that was unresectable, or isolated
metastases whose regression or stabilization would offer potential benefit to the patient. Written
informed consent was obtained from all patients stating that they were aware of the
investigational nature of this study, in keeping with institutional policies. Pretreatment tumor
biopsies demonstrating overexpression of the p53 protein by the criteria of Nishio et al. (19) were required for entry in the protocol. Mutations in the p53 gene
were identified by single-strand conformation polymorphism (SSCP) analysis and DNA
sequencing of a tumor biopsy specimen as described previously (20). All
mutations were reconfirmed by repeated sequencing or SSCP analysis of a second independent
polymerase chain reaction (PCR) reaction. Patients were not treated on protocol until 4 weeks
after completing systemic or local therapy. The preclinical safety studies and treatment protocol
have been described previously (21,22). Ad-p53 was diluted in
phosphate-buffered saline and administered by needle injection directly into the tumor, either
percutaneously or bronchoscopically. For lesions at least 4 cm in the largest diameter, the final
volume given was 10 mL; for lesions with a diameter of less than 4 cm, the final volume given
was 3 mL. The entire volume was injected at a single site. Patients were treated monthly for up to
six injections of Ad-p53. Doses were escalated from 106 plaque-forming units
(PFU) to 1011 PFU in one-half or one log increments (Table 1).
|
Toxicity and response. The toxic effects of therapy were evaluated according to the National Cancer Institute's Common Toxicity Criteria (23). Response to therapy was assessed by chest roentgenogram or CT scans before each course of treatment, by use of standard criteria (14). Responses were confirmed by two evaluations taken 4 weeks apart. Patients were evaluable for response if they had received at least one course of therapy followed by an appropriate radiograph to document response. Response criteria were defined as follows: 1) complete response, i.e., disappearance of all clinical evidence of tumor by physical examination, roentgenography, and CT (or magnetic resonance imaging) scans for a minimum of 4 weeks; 2) partial response, i.e., a 50% or greater decrease in the sum of the products of the perpendicular diameters of measurable lesions for a minimum of 4 weeks and no simultaneous increase of at least 25% in the size of any lesion or the appearance of any new lesion; 3) stable disease, i.e., any variation of the indicator lesion not meeting the criteria of a complete or partial response or progression; and 4) progressive disease, i.e., an increase of at least 25% in the size of a bidimensionally or unidimensionally measurable lesion, a clinically significant increase in the size of noninjected disease, or the appearance of any unequivocal new lesion.
Terminal deoxynucleotide transferase (TdT)-mediated biotin uridine triphosphate
nick-end labeling (TUNEL) assay for DNA fragmentation. Pretreatment (immediately
before) and posttreatment (3 days after) tumor biopsy specimens were obtained by core biopsies
of the vector-injected tumor after each course of treatment (Fig. 1). The
TUNEL assay was a modification of a previously described technique (24,25). Slides were counterstained with 0.4% methylene green. Negative controls
were performed by omitting TdT from the buffer solution, and positive controls included analysis
of deoxyribonuclease-treated slides. Corresponding hematoxylin-eosin slides were evaluated for
the presence of an inflammatory cell infiltrate and were graded on a scale of 1-4. All histology
slides were coded and read blinded by a single observer, who had no knowledge of the patients,
biopsy sequence, or the clinical status.
|
Reverse transcription (RT)-PCR and DNA PCR. Total RNA extraction, RT, PCR amplification, and blot hybridization were performed by a modification of a previously described technique (26,27). A nested PCR procedure was used, with vector-specific primers CMV3 (5'-GGTGCATTGGAACGCGGATT-3') and Rev Ex3 (5'-CAAATCATCC ATTGCTTGGGA-3') used for the first round and CMV3 and RN3 (5'-GGGGACAGAACGTTGTTTTC-3') used for the second round of amplification. Human glyceraldehyde-3-phosphate dehydrogenase (GAPDH) primers (GAPDH-S [5'-CAGCCGAGCCACATC-3'] and GAPDH-AS [5'-TGAGGCTGTTGTCATACTTCT-3']) were used as a positive reaction control, and saline was used as a negative control. All samples underwent PCR amplification without prior reverse transcriptase treatment to test for completeness of deoxyribonuclease digestion. RT-PCR amplification was not performed if DNA PCR was negative for adenoviral DNA or biopsy samples were inadequate for RNA evaluation. DNA PCR was performed on DNA extracted from biopsy specimens by use of the primers described above.
Statistical methods. Because of the small sample size, descriptive statistics were reported in tabular form. Ninety-five percent confidence intervals (CIs) were constructed to estimate the pretreatment apoptotic index (AI). Patients were considered to have increased apoptotic activity if the posttreatment AI was greater than the upper end of the 95% CI of the pretreatment AI. The overall survival was calculated by the Kaplan-Meier estimate. Survival time was defined as time from study entry to death or date of last follow-up.
|
RESULTS |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
|---|
Patient and Tumor Characteristics
Twenty-eight NSCLC patients (17 females and 11 males) with a median
age of 65 years (range, 42-78 years) were entered in the study (Table
1
) beginning October 24, 1995, until December 8, 1997. Partial
information on 12 of these patients was reported previously
(28), together with information on nine patients who received
Ad-p53 and cisplatin in a companion study. A total of 84 courses were
administered, and the date of last follow-up was March 31, 1998 (median
follow-up of 421 days). Patients had documented p53 mutations and
histologically determined, viable non-small-cell lung carcinoma as
judged by pretreatment tumor biopsies. Patients were treated either
percutaneously with the use of CT guidance (23 patients) or
bronchoscopically (five patients). Before entry in the study, all
patients demonstrated progressing primary or metastatic lesions that
had failed to respond to conventional therapies, including surgery in
10 patients (36%), radiation therapy in 25 (89%), and
chemotherapy in 21 (75%). Vector-injected tumors were located in
the lung parenchyma in 14 patients (50%), chest wall in two
patients (7%), bronchus in five patients (18%), liver in five
patients (18%), axilla in one patient (4%), and subcarinal node
in one patient (4%).
Assessment of Gene Transfer
We performed PCR analysis with vector-specific primers for the
adenovirus and p53 sequences to differentiate between vector-transduced
p53 and cellular p53 (Table 2). No pretreatment tumor
biopsy samples showed evidence of adenoviral p53 DNA (DNA-PCR) or
messenger RNA (mRNA) (RT-PCR) sequences. DNA extracted from 18 of 21
evaluable tumors showed vector-specific adenovirus sequences. All
patients who received more than 106 PFU showed evidence of
adenovirus sequences by DNA-PCR in their posttreatment specimens.
Vector-specific mRNA p53 sequences were detected by RT-PCR in 12 of 26
evaluable specimens. Transgene expression of p53 was noted in nine of
16 patients treated at doses above 109 PFU, as opposed to
only three of 10 patients treated with 109 PFU or less.
Transgene expression of p53 occurred after initial and subsequent
treatments at all dose levels above 106 PFU.
|
The mean pretreatment AI was 3.6% (95% CI = 1.5%-5.8%). After administration of Ad-p53, 11 of 24 evaluable patients fell outside the pretreatment 95% CIs with apoptotic indices of 7%-87% in posttreatment tumor biopsy samples (Table 2
). No consistent change in
inflammatory cell infiltration was seen after Ad-p53 treatment in posttreatment tumor biopsy
samples (data not shown). Adverse Events
Vector-related adverse events were minimal (Table
3). No grade 4 toxicity was seen and grade 3
vector-related toxicity was limited to one incident of nausea after
Ad-p53 injection. CT-guided administration of vector resulted in six
pneumothoraces that were treated with percutaneous placement of a
pigtail catheter in two patients and observation in four patients.
Injection site pain was noted during 13 courses (15.5%) and was
resolved with oral pain medications in all patients. Four incidents of
transient hemoptysis were noted after bronchoscopic injection and were
resolved with observation. The most common vector-associated adverse
event was fever, occurring 6-24 hours after injection in 23 treatments
(27.4%). These fevers were treated with antipyretics or observation
and resolved within the next 24-48 hours. There was no increase in
adverse events with repeat treatments or higher doses of Ad-p53, and
dose-limiting Ad-p53 toxicity was not reached in this trial. In
addition, no patient demonstrated hypotension or anaphylaxis despite
repeated (up to six) doses of Ad-p53.
|
Effect on Tumor Growth
Clinical response of the injected tumor was evaluable in 25 patients (89%) and included the following: partial response in two patients (8%; 95% CI = 1%-26%), stabilization of disease in 16 patients (64%; 95% CI = 43%-82%) (range, 2-14 months), and progression of disease in seven patients (28%; 95% CI = 12%-49%). Three patients were not evaluable because they died from treatment problems unrelated to Ad-p53 before a 30-day follow-up CT scan was done. Of note, three of five patients who received less than 108 PFU of Ad-p53 showed continued progression of their disease while on treatment, whereas only four of 22 patients receiving 108 PFU or more showed disease progression. There was no clear relationship between patient characteristics, adverse events, gene expression, or tumor location/size/histology and clinical response. Details of the two patients (patients K and O) who demonstrated a partial response following Ad-p53 gene therapy are as follows:
Patient K presented with a left upper lobe large-cell carcinoma on November 1994. Because
of poor results on pulmonary function tests, the patient was judged not to be a surgical candidate
and was treated with 66 Gy of external beam radiation therapy. The primary tumor recurred in
February 1996 and was treated with six cycles of paclitaxel and carboplatin. The patient was
subsequently enrolled in the gene therapy protocol because the tumor had progressed. At a dose
level of 109 PFU of Ad-p53, the tumor responded with a greater than 50%
decrease in size (Fig. 2). No viable tumor was demonstrated on tumor
biopsies after the first two courses of Ad-p53 therapy. After completion of gene therapy in June
1997, the patient was observed without further treatment and, at the time of the last follow-up
(March 1998), showed no evidence of recurrent disease.
|
In September 1994, patient O was found by bronchoscopy to have an adenocarcinoma that was partially obstructing the left upper lobe. The patient was treated with two courses of cisplatin and etoposide, followed by 60 Gy of definitive external beam radiation therapy. In December 1995, the tumor recurred with bronchial obstruction of the left upper lobe and was treated with laser therapy and 21 cycles of mitomycin C and navelbine. One year later, in December 1996, the patient's left upper lobe of the bronchus was found to be reoccluded; laser therapy was attempted but failed. Direct intratumoral injection of 3 x 109 PFU of Ad-p53 was begun in December 1996, resulting in a partial response and reopening of the airway (Fig. 3).
This response was maintained for 6 months with Ad-p53 alone. At the
completion of therapy, residual tumor still remained and three additional courses of carboplatin
and docetaxol were given, resulting in a complete histologic response. One year later, in
December 1997, the tumor recurred, and the patient was begun on a follow-up Ad-p53 protocol,
which was discontinued because of further tumor progression.
|
The median survival of all patients from the time of initiating gene therapy was 141 days (Fig. 4).
At the time of last follow-up, five patients were still alive greater
than 10 months after initiating therapy and two patients were being observed off all treatment
without evidence of tumor growth.
|
|
DISCUSSION |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
|---|
The estimated incidence of lung cancer in the United States in 1997 was 178 100, with more than 160 400 deaths (29). Despite advances in chemotherapy, radiation therapy, and surgery, overall survival for this disease is still less than 13% (29). Because of the poor results obtained with conventional therapy alone, additional treatment strategies are needed. Our study evaluated the novel strategy of intratumoral injection of an adenovirus vector expressing wt-p53 (Ad-p53) in patients with advanced NSCLC whose cancers had failed to respond to conventional treatments.
One important finding of this study was that multiple doses of Ad-p53 could be administered safely. We have reported previously (28), in an article that described findings for 12 of the patients in this study, that neutralizing anti-adenovirus antibodies rise sharply in the serum after the first course of Ad-p53 and remain elevated throughout therapy. Despite this fact, we observed no major vector-related toxicity with repeat injections. A total of 84 doses of Ad-p53 were delivered; 56 of these doses were repeat injections (up to six injections given monthly). There were no anaphylactic reactions or episodes of hypotension and only one grade 3 vector-related adverse event (nausea) during treatment. All other toxic effects were grade 1 or 2 and consisted primarily of transient fevers treated with antipyretics. Repeated delivery of the vector by CT guidance or bronchoscopy was also feasible, and only six pneumothoraces developed during 84 injections. These pneumothoraces were treated with observation in four patients and with placement of a pigtail catheter in two patients. In addition, pain at the site of injection was noted in only 13 of 84 courses of therapy. Such pain was treated with analgesics and resolved within the first 24-48 hours of injection in most cases. Clayman et al. (30) also noted pain at the injection site as being the most common adverse event after intratumoral injection of Ad-p53 in patients with recurrent head and neck squamous cell carcinoma. In our study, a maximum tolerated dose was not reached. Dose escalation was limited by the protocol to 1011 PFU. Similarly, Sterman et al. (31) found that a dose-limiting toxicity was not reached after intrapleural instillation of up to 1012 PFU of an adenovirus vector, Ad-HSV-tk, containing the herpes simplex virus-thymidine kinase gene into patients with mesothelioma. Because of the low toxicity, 10 patients at the end of the study were able to be treated as outpatients rather than as inpatients, even though six of them were receiving the highest dose of Ad-p53. This low toxicity is important for future trials because it means that Ad-p53 has potentially a high therapeutic index that allows it to be used in combination with other conventional treatments, such as chemotherapy, radiation therapy, or surgery.
The second important observation of this trial was that wt-p53 cDNA transfer and expression
could be accomplished and documented in a large number of patients. We used vector-specific
primers that incorporated flanking regions of the adenovirus to ensure detection of adenovirally
transferred p53 mRNA rather than of native p53. Adenovirus-mediated p53 cDNA transfer
appeared to be dose related. Transgene p53 expression could be documented by RT-PCR in
56% of the patients treated with 109 PFU or more, whereas only 30%
of patients who received lower doses showed transgene p53 expression (Table 2). Importantly, Ad-p53 transgene expression could still be observed after multiple
courses even in the presence of high serum levels of anti-adenovirus antibodies. Sterman et al. (31) also noted dose-related gene expression when mesothelioma patients
were treated with intrapleural instillation of Ad-HSV-tk. In addition, Tursz et al. (32) documented increasing ß-galactosidase expression in patients with
endobronchial lung cancer following intratumoral injection of higher doses of an adenovirus
vector containing the ß-galactosidase gene. Since maximal adenovirus expression occurs in vitro at 3 days and drops off rapidly during the next week, our observation that
transgene expression still occurs with multiple courses may be important for future clinical trials
that require prolonged periods of transgene expression. Detection of gene expression following
transfer of wt-p53 in vivo is difficult because successful transfer and expression of
wt-p53 in a tumor may compromise evidence of gene expression by the rapid induction of
apoptosis. Other constraints on detection of p53 transgene expression in this study are the small
size and scant cellularity of the biopsy specimens and the low sensitivity of the RT-PCR assay (33). These findings may explain in part the variation noted in PCR and
RT-PCR assays performed on sequential biopsy samples.
The third important finding was that evidence of antitumor activity was suggested following Ad-p53 cDNA transfer. Two patients demonstrated a greater than 50% reduction in tumor size after Ad-p53 injection. In one patient, no viable tumor cells could be demonstrated in all biopsy specimens obtained during the last 4 months of treatment. Because of a lack of histologic evidence of cancer following treatment with Ad-p53 alone, we elected to observe this patient off all therapy; at last follow-up—more than 18 months after starting treatment—the patient was without evidence of recurrent tumor. Patients with endobronchial tumors may also represent a subset of patients who could benefit from Ad-p53 treatment, since we observed almost complete regression of a left upper lobe endobronchial tumor that had failed to respond to chemotherapy, radiation therapy, and laser treatment. To our knowledge, this is the first study to demonstrate sustained antitumor activity in NSCLC with gene transfer of wt-p53 alone. Since these patients had already failed to respond to multiple other treatments, future trials with untreated patients or with patients with earlier stage disease may have higher response rates. In addition, Clayman et al. (30) noted that Ad-p53 resulted in the partial regression of disease in two of 17 evaluable patients with recurrent head and neck carcinoma. These results suggest that the antitumor activity noted with Ad-p53 treatment may be effective in other types of cancer. Because of heterogeneity in patients and tumors entered in this phase I study, definitive statements about clinical efficacy are difficult. No clear association could be demonstrated between patient and tumor characteristics and response; however, it did appear that higher doses of Ad-p53 (>108 PFU) were associated with longer times to disease progression. It is interesting that both patients who responded demonstrated continued disease regression with repeated administrations of Ad-p53, even in the face of elevated anti-adenovirus antibodies. Li et al. (34) have shown in an immunocompetent mouse model that multiple intratumoral injections of Ad-p53 result in increased tumor regression and transgene expression despite elevated levels of circulating adenovirus antibodies. These observations validate the strategy of administering multiple intratumoral injections of Ad-p53 to maximize transgene expression and tumor response.
Although immune-mediated responses have been reported after adenovirus treatment (35), we observed no evidence of a substantial increase in inflammatory
cell infiltrates in posttreatment tumor biopsy specimens. In addition, despite increases in
neutralizing levels of anti-adenovirus antibodies and increased lymphocyte proliferative
responses to adenovirus serotype 5 antigens, no antibody-dependent cytotoxicity could be
demonstrated in posttreatment serum samples, and changes in lymphocyte proliferative responses
to p53 mutant and wild type were not observed (Yen N, Ioannides CG, Xu K, Swisher SG,
Lawrence DD, Kemp BL, et al.: unpublished observations). Moreover, preclinical studies have
demonstrated in both immunocompetent and immunodeficient animal models an antitumor
activity that appears to be p53 specific (7,8,10,12). It is unlikely,
therefore, that the antitumor activity we observed in this trial was due to immune-mediated
effects. Another possible mechanism for the antitumor effects is the induction of apoptosis by
Ad-p53. We have observed that the transduction of human lung cancer cells with Ad-p53 results
in the increase of the pro-apoptotic Bcl-2 family members Bax and Bak (36). This mechanism is supported by the high levels of apoptosis seen with TUNEL
staining in the posttreatment tumor biopsy samples from 11 of 24 evaluable patients. In the two
patients who responded to Ad-p53, one patient demonstrated a posttreatment AI of 46%,
while the other patient could not be evaluated because of the large amount of necrosis after
treatment. In addition, since posttreatment tumor biopsies were always performed 3 days after
Ad-p53 injection, the critical period of apoptosis may have been missed in some patients because
in vitro studies (37) suggest that apoptosis can occur as soon as
3 hours after induction. It is interesting, however, that, in those patients who demonstrated
TUNEL activity, TdT expression was markedly higher than that reported in patients following
chemotherapy. Ueda et al. (38) noted only two of 22 patients with an AI
greater than 10% after intra-arterial infusion of chemotherapy in cervical carcinoma,
whereas we noted four patients with an AI ranging from 47% to 87% after Ad-p53
treatment (Table 2). Intratumoral injection of retroviral p53 has also been
associated with increased TUNEL activity (14), which suggests that
induction of apoptosis by transgene expression of wt-p53 may be one of the mechanisms
underlying tumor regression.
In summary, this study demonstrates for the first time, to our knowledge, the clinical feasibility of adenoviral p53 cDNA transfer strategies in NSCLC. The safety and efficacy of repeated doses, even in large, established tumors, suggest that a therapeutic window exists during which clinical benefit is not accompanied by additional toxicity. Several potential clinical applications of this technology exist. At the present time, local control of lung cancer remains suboptimal. Radiation therapy is limited in effectiveness because of toxicity to normal tissues at higher doses. Since preclinical studies suggest synergism between radiation and Ad-p53 without increased toxicity, one potential strategy might be to combine the two modalities for enhanced local tumor control (39). Another possibility is in premalignant lesions, such as bronchial dysplasias, where p53 mutations are known to precede invasive carcinoma (40,41). Localized injection of a nontoxic agent such as Ad-p53 might ultimately play a role in preventing the development of invasive cancer. Phase II clinical trials are now under way to determine the feasibility of these strategies and to determine the clinical role of Ad-p53 in the treatment of lung cancer.
|
NOTES |
|---|
Editor's note: J. A. Roth is a scientific advisor to Introgen Therapeutics, Inc., of Houston, TX, which sponsored the clinical trial and supplied the Ad-p53 vector used in it, and he holds stock in the company. Roth continues to conduct research sponsored by Introgen Therapeutics, Inc. J. A. Merritt, an employee of Introgen Therapeutics, Inc., holds options on the company's stock.
Supported by Public Health Service grants R01CA45187, P50CA70907, and CA16672 from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services; by gifts to the Division of Surgery and Anesthesiology from Tenneco and Exxon for the Core Laboratory Facility; by a grant from the Mathers Foundation; and by a sponsored research agreement with Introgen Therapeutics, Inc. Additional support for the clinical trial came from R. P. R. Gencell, Collegeville, PA.
We thank the patients and their families who participated in this study; M. M. Dolormente, F. D. Martin, E. Brown, R. Francisco, and G. Johnson, who were research nurses for the study; T. Timmons and A. Hutchison from Introgen Therapeutics, Inc.; N. Yen, C. Branch, and K. Xu for technical assistance; B. Bready, L. Trissel, R. Anderson, and the Division of Pharmacy, The University of Texas M. D. Anderson Cancer Center; E. Janssen for monitoring biosafety; D. Rusnak and D. Fattig for assistance in preparing protocol submissions; T. Anderson, B. Brooks, C. Denham, L. Duncan, L. Fichtelmeyer, A. Gupda, V. Hirsch, V. Horadam, R. Kerr, R. Mennel, S. Paulson, R. Ruxer, and S. Vukelja for their contribution to patient enrollment; and M. Contreras for preparation of the manuscript.
|
REFERENCES |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
|---|
1
Hartwell LH, Kastan MB. Cell cycle control and cancer. Science 1994;266:1821-8.
2 Kastan MB, Canman CE, Leonard CJ. p53, cell cycle control and apoptosis: implications for cancer. Cancer Metastasis Rev 1995;14:3-15.[CrossRef][ISI][Medline]cancerlit;95330851
3 Mukhopadhyay T, Maxwell SA, Roth JA. p53 suppressor gene. Austin (TX): R. G. Landes Co.; 1995.
4 Spitz FR, Nguyen D, Skibber JM, Meyn RE, Cristiano RJ, Roth JA. Adenoviral-mediated wild-type p53 gene expression sensitizes colorectal cancer cells to ionizing radiation. Clin Cancer Res 1996;2:1665-71.[Abstract]cancerlit;99035194
5 Lowe SW, Schmitt EM, Smith SW, Osborne BA, Jacks T. p53 is required for radiation-induced apoptosis in mouse thymocytes. Nature 1993;362:847-9.[CrossRef][Medline]cancerlit;93241298
6 Lowe SW, Ruley HE, Jacks T, Housman DE. p53-dependent apoptosis modulates the cytotoxicity of anticancer agents. Cell 1993;74:957-67.[CrossRef][ISI][Medline]cancerlit;94006528
7
Fujiwara T, Cai DW, Georges RN, Mukhopadhyay T, Grimm
EA, Roth JA. Therapeutic effect of a retroviral wild-type p53 expression vector in an orthotopic
lung cancer model. J Natl Cancer Inst 1994;86:1458-62.
8 Zhang WW, Fang X, Mazur W, French BA, Georges RN, Roth JA. High-efficiency gene transfer and high-level expression of wild-type p53 in human lung cancer cells mediated by recombinant adenovirus. Cancer Gene Ther 1994;1:5-13.[ISI][Medline]cancerlit;95346687
9 Kock H, Harris MP, Anderson SC, Machemer T, Hancock W, Sutjipto S, et al. Adenovirus-mediated p53 gene transfer suppresses growth of human glioblastoma cells in vitro and in vivo. Int J Cancer 1996;67:808-15.[CrossRef][ISI][Medline]cancerlit;96421935
10 Harris MP, Sutjipto S, Wills KN, Hancock W, Cornell D, Johnson DE, et al. Adenovirus-mediated p53 gene transfer inhibits growth of human tumor cells expressing mutant p53 protein. Cancer Gene Ther 1996;3:121-30.[ISI][Medline]cancerlit;96280244
11 Mujoo K, Maneval DC, Anderson SC, Gutterman JU. Adenoviral-mediated p53 tumor suppressor gene therapy of human ovarian carcinoma. Oncogene 1996;12:1617-23.[ISI][Medline]cancerlit;96201641
12 Nielsen LL, Dell J, Maxwell E, Armstrong L, Maneval D, Catino JJ. Efficacy of p53 adenovirus-mediated gene therapy against human breast cancer xenografts. Cancer Gene Ther 1997;4:129-38.[ISI][Medline]cancerlit;97234932
13 Wills KN, Maneval DC, Menzel P, Harris MP, Sutjipto S, Vaillancourt MT, et al. Development and characterization of recombinant adenoviruses encoding human p53 for gene therapy of cancer. Hum Gene Ther 1994;5:1079-88.[ISI][Medline]cancerlit;95134785
14 Roth JA, Nguyen D, Lawrence DD, Kemp BL, Carrasco CH, Ferson DZ, et al. Retrovirus-mediated wild-type p53 gene transfer to tumors of patients with lung cancer. Nat Med 1996;2:985-91.[CrossRef][ISI][Medline]cancerlit;96376348
15 Stratford-Perricaudet LD, Perricaudet M. Gene therapy: the advent of adenovirus. In: Wolff JA, editor. Gene therapeutics: methods and applications of direct gene transfer. Boston (MA): Birkhauser; 1994. p. 344-62.
16 Blaese M, Blankenstein T, Brenner M, Cohen-Haguenauer O, Gansbacher B, Russell S, et al. Vectors in cancer therapy: how will they deliver. Cancer Gene Ther 1995;2:291-7.[ISI][Medline]cancerlit;96136904
17 Roth JA. Clinical protocol for modification of tumor suppressor gene expression and induction of apoptosis in non-small cell lung cancer (NSCLC) with an adenovirus vector expressing wildtype p53 and cisplatin. Hum Gene Ther 1995;6:252-5.
18 Zhang WW, Fang X, Branch CD, Mazur W, French BA, Roth JA. Generation and identification of recombinant adenovirus by liposome-mediated transfection and PCR analysis. Biotechniques 1993;15:868-72.[ISI][Medline]cancerlit;94092464
19
Nishio M, Koshikawa T, Kuroishi T, Suyama M, Uchida K,
Takagi Y, et al. Prognostic significance of abnormal p53 accumulation in primary, resected
non-small-cell lung cancers. J Clin Oncol 1996;14:497-502.
20
Chung KY, Mukhopadhyay T, Kim J, Casson A, Ro JY,
Goepfert H, et al. Discordant p53 gene mutations in primary head and neck cancers and
corresponding second primary cancers of the upper aerodigestive tract. Cancer Res 1993;53:1676-83.
21 Roth JA. Modification of tumor suppressor gene expression and induction of apoptosis in non-small cell lung cancer (NSCLC) with an adenovirus vector expressing wildtype p53 and cisplatin. Hum Gene Ther 1996;7:1013-30.[ISI][Medline]cancerlit;96323654
22 Zhang WW, Alemany R, Wang J, Koch PE, Ordonez NG, Roth JA. Safety evaluation of Ad5CMV-p53 in vitro and in vivo. Hum Gene Ther 1995;6:155-64.[ISI][Medline]cancerlit;95252291
23 Ajani JA, Welch SR, Raber MN, Fields WS, Krakoff IH. Comprehensive criteria for assessing therapy-induced toxicity. Cancer Invest 1990;8:147-59.[ISI][Medline]cancerlit;90381564
24
Fujiwara T, Grimm EA, Mukhopadhyay T, Cai DW,
Owen-Schaub LB, Roth JA. A retroviral wild-type p53 expression vector penetrates human lung
cancer spheroids and inhibits growth by inducing apoptosis. Cancer Res 1993;53:4129-33.
25 Wang J, Bucana CD, Roth JA, Zhang WW. Apoptosis induced in human osteosarcoma cells is one of the mechanisms for the cytocidal effect of Ad5CMV-p53. Cancer Gene Ther 1995;2:9-17.[ISI][Medline]cancerlit;95346708
26 Cai DW, Mukhopadhyay T, Liu Y, Fujiwara T, Roth JA. Stable expression of the wild-type p53 gene in human lung cancer cells after retrovirus-mediated gene transfer. Hum Gene Ther 1993;4:617-24.[ISI][Medline]cancerlit;94107960
27 Cai DW, Mukhopadhyay T, Roth JA. Suppression of lung cancer cell growth by ribozyme-mediated modification of p53 pre-mRNA. Cancer Gene Ther 1995;2:199-205.[ISI][Medline]cancerlit;96051282
28 Roth JA, Swisher SG, Merritt JA, Lawrence DD, Kemp BL, Carrasco CH, et al. Gene therapy for non-small cell lung cancer: a preliminary report of a phase I trial of adenoviral p53 gene replacement. Semin Oncol 1998;25(3 Suppl 8):33-7.[ISI][Medline]
29 Parker SL, Tong T, Bolden S, Wingo PA. Cancer statistics, 1997. CA Cancer J Clin 1997;47:5-27.[ISI][Medline]cancerlit;97149268
30 Clayman GL, el-Naggar AK, Lippman SM, Henderson YC, Frederick M, Merritt JA, et al. Adenovirus-mediated p53 gene transfer in patients with advanced recurrent head and neck squamous cell carcinoma. J Clin Oncol 1998;16:2221-32.[Abstract]cancerlit;98289464
31 Sterman DH, Treat J, Litzky LA, Amin KM, Coonrod L, Molnar-Kimber K, et al. Adenovirus-mediated herpes simplex virus thymidine kinase/ganciclovir gene therapy in patients with localized malignancy: results of a phase I clinical trial in malignant mesothelioma. Hum Gene Ther 1998;9:1083-92.[ISI][Medline]cancerlit;98268435
32
Tursz T, Cesne AL, Baldeyrou P, Gautier E, Opolon P, Schatz
C, et al. Phase I study of a recombinant adenovirus-mediated gene transfer in lung cancer
patients. J Natl Cancer Inst 1996;88:1857-63.
33 Johnson LG, Pickles RJ, Boyles SE, Morris JC, Ye H, Zhou Z, et al. In vitro assessment of variables affecting the efficiency and efficacy of adenovirus-mediated gene transfer to cystic fibrosis airway epithelia. Hum Gene Ther 1996;7:51-9.[ISI][Medline]
34 Li Z, Rakkar A, Katayose Y, Kim M, Shanmugam N, Srivastava S, et al. Efficacy of multiple administrations of a recombinant adenovirus expressing wild-type p53 in an immune-competent mouse tumor model. Gene Ther 1998;5:605-13.[CrossRef][ISI][Medline]cancerlit;99014598
35
Dai Y, Schwarz EM, Gu D, Zhang WW, Sarvetnick N, Verma
IM. Cellular and humoral immune responses to adenoviral vectors containing factor IX gene:
tolerization of factor IX and vector antigens allows for long-term expression. Proc Natl
Acad Sci U S A 1995;92:1401-5.
36 Pearson AS, Spitz FR, Swisher SG, Kataoka M, Sarkiss MG, Meyn RE, et al. Upregulation of the proapoptotic mediators bax and bak following adenovirus-mediated p53 gene transfer in lung cancer cells. Clin Cancer Res. In press 1999.
37
Bursch W, Paffe S, Putz B, Barthel G, Schulte-Hermann R.
Determination of the length of the histological stages of apoptosis in normal liver and in altered
hepatic foci of rats. Carcinogenesis 1990;11:847-53.
38
Ueda M, Ueki K, Kumagai K, Terai Y, Okamoto Y, Ueki M, et
al. Apoptosis and tumor angiogenesis in cervical cancer after preoperative chemotherapy. Cancer Res 1998;58:2343-6.
39 Spitz F, Nguyen D, Skibber J, Meyn R, Cristiano R, Roth J. Enhancement of radiation sensitivity of colorectal cancer cells by adenovirus-mediated p53 gene therapy. Surg Forum 1996;47:481-4.
40
Sozzi G, Miozzo M, Donghi R, Pilotti S, Cariani CT, Pastorino
U, et al. Deletions of 17p and p53 mutations in preneoplastic lesions of the lung. Cancer Res 1992;52:6079-82.
41 Brambilla E, Gazzeri S, Lantuejoul S, Coll JL, Moro D, Negoescu A, et al. p53 mutant immunophenotype and deregulation of p53 transcription pathway (Bc12, Bax, and Waf1) in precursor bronchial lesions of lung cancer. Clin Cancer Res 1998;4:1609-18.[Abstract]cancerlit;98339456
Manuscript received September 8, 1998; revised January 26, 1999; accepted March 1, 1999.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  V. Keedy, W. Wang, J. Schiller, S. Chada, B. Slovis, K. Coffee, J. Worrell, L. A. Thet, D. H. Johnson, and D. P. Carbone Phase I Study of Adenovirus p53 Administered by Bronchoalveolar Lavage in Patients With Bronchioloalveolar Cell Lung Carcinoma: ECOG 6597 J. Clin. Oncol., September 1, 2008; 26(25): 4166 - 4171. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Sasaki, H. Negishi, M. Idogawa, H. Suzuki, H. Mita, M. Toyota, Y. Shinomura, K. Imai, and T. Tokino Histone deacetylase inhibitor FK228 enhances adenovirus-mediated p53 family gene therapy in cancer models Mol. Cancer Ther., April 1, 2008; 7(4): 779 - 787. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Zou, C. Tornos, X. Qiu, M. Lia, and R. Perez-Soler p53 Aerosol Formulation with Low Toxicity and High Efficiency for Early Lung Cancer Treatment Clin. Cancer Res., August 15, 2007; 13(16): 4900 - 4908. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. W. Tolcher, D. Hao, J. de Bono, A. Miller, A. Patnaik, L. A. Hammond, L. Smetzer, J. Van Wart Hood, J. Merritt, E. K. Rowinsky, et al. Phase I, Pharmacokinetic, and Pharmacodynamic Study of Intravenously Administered Ad5CMV-p53, an Adenoviral Vector Containing the Wild-Type p53 Gene, in Patients With Advanced Cancer J. Clin. Oncol., May 1, 2006; 24(13): 2052 - 2058. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Fujiwara, N. Tanaka, S. Kanazawa, S. Ohtani, Y. Saijo, T. Nukiwa, K. Yoshimura, T. Sato, Y. Eto, S. Chada, et al. Multicenter Phase I Study of Repeated Intratumoral Delivery of Adenoviral p53 in Patients With Advanced Non-Small-Cell Lung Cancer J. Clin. Oncol., April 10, 2006; 24(11): 1689 - 1699. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Fabbri, D. Iliopoulos, F. Trapasso, R. I. Aqeilan, A. Cimmino, N. Zanesi, S. Yendamuri, S.-Y. Han, D. Amadori, K. Huebner, et al. WWOX gene restoration prevents lung cancer growth in vitro and in vivo PNAS, October 25, 2005; 102(43): 15611 - 15616. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Osborne, P. Wilson, and D. Tripathy Oncogenes and Tumor Suppressor Genes in Breast Cancer: Potential Diagnostic and Therapeutic Applications Oncologist, July 1, 2004; 9(4): 361 - 377. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Murakami, N. Tokunaga, T. Waku, S. Gomi, S. Kagawa, N. Tanaka, and T. Fujiwara Antitumor Effect of Intratumoral Administration of Bone Marrow-Derived Dendritic Cells Transduced with Wild-Type p53 Gene Clin. Cancer Res., June 1, 2004; 10(11): 3871 - 3880. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. L. Pisters, C. A. Pettaway, P. Troncoso, T. J. McDonnell, L. C. Stephens, C. G. Wood, K.-A. Do, S. M. Brisbay, X. Wang, E. A. Hossan, et al. Evidence That Transfer of Functional p53 Protein Results in Increased Apoptosis in Prostate Cancer Clin. Cancer Res., April 15, 2004; 10(8): 2587 - 2593. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y Tsunemitsu, S Kagawa, N Tokunaga, S Otani, T Umeoka, J A Roth, B Fang, N Tanaka, and T Fujiwara Molecular therapy for peritoneal dissemination of xenotransplanted human MKN-45 gastric cancer cells with adenovirus mediated Bax gene transfer Gut, April 1, 2004; 53(4): 554 - 560. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Barzon, M. Boscaro, and G. Palu Endocrine Aspects of Cancer Gene Therapy Endocr. Rev., February 1, 2004; 25(1): 1 - 44. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Ohtani, S. Kagawa, Y. Tango, T. Umeoka, N. Tokunaga, Y. Tsunemitsu, J. A. Roth, Y. Taya, N. Tanaka, and T. Fujiwara Quantitative analysis of p53-targeted gene expression and visualization of p53 transcriptional activity following intratumoral administration of adenoviral p53 in vivo Mol. Cancer Ther., January 1, 2004; 3(1): 93 - 100. [Abstract] [Full Text]
|
|
|
|
|
|
T. Kawashima, S. Kagawa, N. Kobayashi, Y. Shirakiya, T. Umeoka, F. Teraishi, M. Taki, S. Kyo, N. Tanaka, and T. Fujiwara Telomerase-Specific Replication-Selective Virotherapy for Human Cancer Clin. Cancer Res., January 1, 2004; 10(1): 285 - 292. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Terui, K. Murakami, R. Takimoto, M. Takahashi, K. Takada, T. Murakami, S. Minami, T. Matsunaga, T. Takayama, J. Kato, et al. Induction of PIG3 and NOXA through Acetylation of p53 at 320 and 373 Lysine Residues as a Mechanism for Apoptotic Cell Death by Histone Deacetylase Inhibitors Cancer Res., December 15, 2003; 63(24): 8948 - 8954. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. A. Lanson Jr., P. L. Friedlander, P. Schwarzenberger, J. K. Kolls, and G. Wang Replication of an Adenoviral Vector Controlled by the Human Telomerase Reverse Transcriptase Promoter Causes Tumor-Selective Tumor Lysis Cancer Res., November 15, 2003; 63(22): 7936 - 7941. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Moon, Y. Oh, and J. A. Roth Current Status of Gene Therapy for Lung Cancer and Head and Neck Cancer Clin. Cancer Res., November 1, 2003; 9(14): 5055 - 5067. [Abstract] [Full Text] [PDF] |