U.S. patent application number 13/035692 was filed with the patent office on 2011-11-03 for effective sensitizing dose of a gelled immunomodulating topical composition.
This patent application is currently assigned to HAPTEN PHARMACEUTICALS, LLC. Invention is credited to John G. Callahan, Leonard L. Kaplan, William R. Levis.
Application Number | 20110268761 13/035692 |
Document ID | / |
Family ID | 44542510 |
Filed Date | 2011-11-03 |
United States Patent
Application |
20110268761 |
Kind Code |
A1 |
Levis; William R. ; et
al. |
November 3, 2011 |
Effective Sensitizing Dose of a Gelled Immunomodulating Topical
Composition
Abstract
The present invention relates to compositions and methods of
treating warts and other human papilloma virus (HPV) skin
infections. The present invention relates to compositions and
methods of treating skin cancer.
Inventors: |
Levis; William R.; (New
York, NY) ; Kaplan; Leonard L.; (East Brunswick,
NJ) ; Callahan; John G.; (Moorestown, NJ) |
Assignee: |
HAPTEN PHARMACEUTICALS, LLC
|
Family ID: |
44542510 |
Appl. No.: |
13/035692 |
Filed: |
February 25, 2011 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
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61309717 |
Mar 2, 2010 |
|
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Current U.S.
Class: |
424/204.1 ;
514/683 |
Current CPC
Class: |
A61K 47/26 20130101;
A61P 35/00 20180101; A61K 47/10 20130101; A61K 31/122 20130101;
A61P 17/12 20180101; A61K 9/0014 20130101; A61K 47/14 20130101;
A61K 9/06 20130101; A61P 31/20 20180101 |
Class at
Publication: |
424/204.1 ;
514/683 |
International
Class: |
A61K 39/12 20060101
A61K039/12; A61P 35/00 20060101 A61P035/00; A61P 31/20 20060101
A61P031/20; A61K 31/122 20060101 A61K031/122; A61P 17/12 20060101
A61P017/12 |
Claims
1. A method of treating a disease or disorder associated with human
papilloma virus infection in a human patient, the method comprising
administering to a first site on the skin of a human patient a low
sensitizing dose of an immunomodulating gel composition followed by
a subsequent administration to a second site on the skin of said
patient a challenge dose of said immunomodulating gel composition,
wherein said composition comprises diphenylcyclopropenone
(DPCP).
2. The method of claim 1, wherein said disease or disorder
associated with human papilloma virus infection is selected from
the group consisting of common warts, plantar warts, inguinal
warts, venereal warts, and any combination thereof.
3. The method of claim 1, wherein said low sensitizing dose is in
the range of about 0.4% DPCP to about 0.6% DPCP, and wherein said
challenge dose is in the range of about 0.04% DPCP to about 0.1%
DPCP.
4. The method of claim 1, wherein said low sensitizing dose is
about 0.4% DPCP, and wherein said challenge dose is about 0.04%.
DPCP.
5. The method of claim 1, wherein a subsequent challenge dose is
administered to the skin of said patient daily.
6. The method of claim 1, wherein a subsequent challenge dose is
administered to the skin of said patient every other day.
7. The method of claim 1, wherein a subsequent challenge dose is
administered to the skin of said patient biweekly.
8. The method of claim 1, wherein a subsequent challenge dose is
administered to the skin of said patient weekly.
9. The method of claim 1, wherein said immunomodulating gel
composition further comprises a gel delivery system comprising: a)
a first co-solvent comprising a non-ionic surfactant, b) a second
co-solvent comprising an alcoholic ester, and c) a gelling
agent.
10. The method of claim 9, wherein said first co-solvent is
selected from the group consisting of polyoxyethylene (20)
monoleate, polyoxyethylene (20) sorbitan monooleate, palmitate and
stearate, and wherein said second co-solvent is selected from the
group consisting of isopropyl myristate and isopropyl palmitate,
and wherein said gelling agent is polyoxyl 40 stearate.
11. A method of treating cancer in a human patient, the method
comprising administering to a first site on the skin of a human
patient a low sensitizing dose of an immunomodulating gel
composition followed by a subsequent administration to a second
site on the skin of said patient a challenge dose of said
immunomodulating gel composition, wherein said composition
comprises diphenylcyclopropenone (DPCP).
12. The method of claim 11, wherein said cancer is selected from
the group consisting of melanoma, cutaneous melanoma, Merkel cell
carcinoma, basal cell carcinoma and it's subtype basal cell nevus
syndrome, squamous cell carcinoma and it's subtype Bowen's Disease,
actinic keratosis, and cutaneous T cell lymphoma and it's subtype
mycosis fungoides.
13. The method of claim 11, wherein said low sensitizing dose is in
the range of about 0.4% DPCP to about 0.6% DPCP, and wherein said
challenge dose is in the range of about 0.04% DPCP to about 0.1%
DPCP.
14. The method of claim 11, wherein said low sensitizing dose is
about 0.4% DPCP, and wherein said challenge dose is about 0.04%
DPCP.
15. The method of claim 11, wherein a subsequent challenge dose is
administered to the skin of said patient daily.
16. The method of claim 11, wherein a subsequent challenge dose is
administered to the skin of said patient every other day.
17. The method of claim 11, wherein a subsequent challenge dose is
administered to the skin of said patient biweekly.
18. The method of claim 11, wherein a subsequent challenge dose is
administered to the skin of said patient weekly.
19. The method of claim 11, wherein said immunomodulating gel
composition further comprises a gel delivery system comprising a
first co-solvent comprising a non-ionic surfactant, a second
co-solvent comprising an alcoholic ester, and a gelling agent.
20. The method of claim 19, wherein said first co-solvent is
selected from the group consisting of polyoxyethylene (20)
monoleate, polyoxyethylene (20) sorbitan monooleate, palmitate and
stearate, and wherein said second co-solvent is selected from the
group consisting of isopropyl myristate and isopropyl palmitate,
and wherein said gelling agent is polyoxyl 40 stearate.
21. A method of treating a disease or disorder associated with
human papilloma virus infection in a human patient, the method
comprising administering to the skin of a human patient a
sensitizing dose of about 0.4% DPCP followed by a challenge dose of
about 0.04% DPCP at 14 days and then weekly challenge doses of
about 0.04% DPCP for at least 6 weeks.
22. A method of treating a disease or disorder associated with
human papilloma virus infection in a human patient, the method
comprising administering to the skin of a human patient a
sensitizing dose of about 0.4% DPCP followed by a challenge dose of
about 0.04% DPCP at 14 days and then biweekly challenge does of
about 0.04% DPCP for at least 6 weeks.
23. A method of treating skin cancer in a human patient, the method
comprising administering to the skin of a human patient a
sensitizing dose of about 0.4% DPCP followed by a challenge dose of
DPCP in the range of about 0.04% to about 0.1% at 14 days and then
biweekly challenge doses of DPCP in the range of about 0.04% to
about 0.1% for a sufficient amount of time.
24. A method of treating skin cancer in a human patient, the method
comprising administering to the skin of a human patient a
sensitizing dose of about 0.4% DPCP followed by a challenge dose of
about 0.04% DPCP at 14 days and then biweekly challenge doses of
about 0.04% DPCP for a sufficient amount of time.
25. A method of enhancing an immune response in a human patient,
the method comprising administering to a first site on the skin of
a human patient a low sensitizing dose of an immunomodulating gel
composition followed by a subsequent administration to a second
site on the skin of said patient a challenge dose of said
immunomodulating gel composition, wherein said composition
comprises diphenylcyclopropenone (DPCP).
Description
BACKGROUND OF THE INVENTION
[0001] Human papilloma virus (HPV) is a small double-stranded DNA
virus that colonizes various stratified epithelia like skin, oral
and genital mucosa, and induces the formation of self-limiting
benign tumors known as papillomas (warts) or condylomas. Most of
these benign tumors naturally regress due to the influence of host
immunological defenses. Some HPVs, however, have oncogenic
potential and have been associated with certain types of cancers.
See, Lorincz et al., Obstetrics & Gynecology, 79:328-337
(1992); Beaudenon et al., Nature, 321:246-249 (1986); and Holloway
et al., Gynecol. Onc., 41:123-128 (1991).
[0002] Infection with HPV is common. HPV can be transmitted
sexually, and it is estimated that 20-80% of sexually active adults
have been infected. While a majority of infections are
asymptomatic, infection can lead to the development of genital
warts (which have a prevalence of about 1-5% among adults) and
cancer of the anogenital tract. Another type of cancer, cervical
cancer, is strongly associated with HPV (Frazer, Genitourin. Med.
72:398-403, 1996). HPV types 6, 11, 16, 18, 31, and 33 are often
associated with an increased risk of cancer, with types 16 and/or
18 being detected in more than 90% of cervical carcinomas (van
Driel et al., Ann. Med. 28:471-477, 1996). Types 6 and 11 are also
associated with anogenital warts. For reviews of papilloma viruses
and their associated pathologies, see Shah et al., "Chapter 66:
Papillomaviruses," In: Virology, 3rd Edition, Fields et al., Eds.,
Raven Press, Philadelphia, pp 2077-2109, 1996, and zur Hausen, J.
Natl. Cancer Inst. 92:690-698, 2000.
[0003] Verrucae or human warts are benign epidermal tumors caused
by human papilloma virus HPV. HPV is a member of the papovavirus
family. HPV is a non-enveloped double-stranded deoxyribonucleic
acid (DNA) virus that replicates in epithelial cells. This means
that HPV has a predilection for the mucosa and skin. Currently,
there are more than 70 distinct HPV types recognized each with at
least a 10% genome difference. Because papillomaviruses tend to be
host-specific and HPV has not been successfully grown in culture;
the majority of the research with papilloma virus has been
conducted with animal papillomaviruses. Papillomaviruses are
considered responsible for several forms of viral infection ranging
from relatively benign warts of the skin or mucous membranes to
cancer, the most significant being cervical cancer.
Papillomaviruses are known to infect mammals, including humans,
rabbits, canines, felines, bovines and equines. Papillomaviruses
are highly species and tissue-specific, and are characterized by a
specific mode of interaction with the squamous epithelia they
infect. These viridae colonize various stratified epithelia like
skin and oral and genital mucosae, and induce the formation of
self-limited benign tumors, known as warts or condylomas.
[0004] An immune response against HPV infection is associated with
cell mediated immune function rather than humoral immune function.
This function is recognized medically as the basis for this
anti-viral activity based on increases in CD4 helper and CD8 killer
T cells with respect to combating HPV infection. Biologically, this
results from Th-1 cell mediated immune responses with release of
cytokines to impart human papilloma virucidal activity. Warts as
human papilloma infections can occur in various forms, i.e., common
warts (verruca vulgaris), plantar warts (verruca plantaris) &
genital warts including venereal and inguinal warts. These are
prevalent among all racial groups.
[0005] Current therapies as wails treatments are divided into three
groups: cellular destruct chemical agents, cryotherapy and
immunomodulators. Cellular destructive therapies include chemical
agents such as podophyllin, trichloroacetic acid, 5-fluorouracil,
bleomycin, retinoids, glutaraldehyde, formaldehyde, salicylic acid
and cantharidin. With cryotherapy, a wart is exposed to liquid
nitrogen for several treatments spread over three to four weeks
required to destruct the warts cellular structure. These treatments
results in varying success depending on the nature and severity of
the wart lesions. The present invention provides a need in the art
for more effective treatments of warts.
[0006] Melanoma is a serious form of skin cancer in humans. It
arises from the pigment cells (melanocytes), usually in the skin.
Melanoma is currently increasing at the fastest rate of all cancers
in the United States. Without even including melanoma in-situ, it
is the seventh most common serious cancer in the United States.
[0007] Melanoma has emerged as the primary model for developing
immunotherapies for several reasons. Histopathologic evidence of
tumor regression is frequently observed within primary melanoma
specimens, along with the presence of tumor infiltrating
lymphocytes, thus suggesting a prominent role for the immune system
in melanoma (Leong et al., 1996 Surg Clin North Am 76: 1355-81).
Melanoma cells readily adapt to tissue culture, resulting in the
creation of panels of melanoma cell lines to study. The paucity of
effective therapies (chemotherapy, radiation) has resulted in a
lower threshold for testing immunological therapies in patients
with melanoma (Wolchok et al., 2001 Lancet Oncol II: 205-11;
Houghton et al., 2001 Curr Opin Immunol 13: 134-40).
[0008] Melanomas are aggressive, frequently metastatic tumors
derived from either melanocytes or melanocyte related nevus cells.
Melanomas make up approximately three percent of all skin cancers
and the worldwide increase in melanoma is unsurpassed by any other
neoplasm with the exception of lung cancer in women. Even when
melanoma is apparently localized to the skin, up to 30% of the
patients will develop systemic metastasis and the majority will die
(Kirkwood and Agarwala (1993) Principles and Practice of Oncology
7:1-16).
[0009] T cells play an important role in tumor regression in most
murine tumor models. Tumor infiltrating lymphocytes (TIL) that
recognize unique cancer antigens can be isolated from many murine
tumors. The adoptive transfer of these TIL plus interleukin-2 can
mediate the regression of established lung and liver metastases
(Rosenberg, S. A., et al., (1986) Science 233:1318-1321). In
addition, the secretion of IFN-.gamma. by injected TIL
significantly correlates with in vivo regression of murine tumors
suggesting activation of T-cells by the tumor antigens (Barth, R.
J., et al., (1991) J. Exp. Med. 173:647-658). The known ability of
tumor TIL to mediate the regression of metastatic cancer in 35 to
40% of melanoma patients when adoptively transferred into patients
with metastatic melanoma attests to the clinical importance of the
antigens recognized (Rosenberg, S. A., et al., (1988) N Engl J Med
319:1676-1680; Rosenberg S. A. (1992) J. Clin. Oncol.
10:180-199).
[0010] Melanomas can metastasize either by the lymphatic or
haematogenous route. About two-thirds of metastases are originally
confined to the drainage area of regional lymph nodes. A regional
metastasis can appear as a micrometastasis in the regional lymph
nodes identified via sentinel lymph node biopsy. In contrast to
macrometastasis, micrometastasis is not clinically recognizable by
palpation or by imaging techniques.
[0011] Classic modalities of treating melanoma include surgery,
radiation and chemotherapy. For example, standard treatment of a
primary tumor is to surgically remove the tumor with adequate
margins. However the management of in-transit disease remains
extremely challenging. Although surgery may be reasonable when the
number of lesions is small, this occurs in only the minority of
cases. In the past decade immunotherapy and gene therapy have
emerged as new and promising methods for treating melanoma.
[0012] Currently, a major treatment for cancerous tumors is
surgical removal of the affected areas of the tissue, organ, or
gland. However, high recurrence rates are a major obstacle to the
complete eradication of cancerous cells. It is believed that
although the cancer cells in the malignant tumors can be removed
surgically, cancerous cells that have invaded the surrounding
tissue or lymph nodes frequently cause tumor recurrence. One reason
for frequent tumor recurrence may be that during the development of
the primary cancer, complete removal of all the cancer cells by
surgical procedures is extremely difficult. Although irradiation,
chemotherapy and appropriate hormone therapy all induce apoptosis
to some extent in tumor cells, higher doses of the drugs or
radiation may be required for suppressing the growth of cancer
cells, which, in turn, can cause severe side effects on
patients.
[0013] Novel strategies are clearly needed to improve the clinical
outcome of HPV infection and melanoma. The present invention
provides a need in the art for more effective treatments of these
diseases.
SUMMARY OF THE INVENTION
[0014] The present invention provides a method of treating a
disease or disorder associated with human papilloma virus infection
in a human patient. The method comprises administering to a first
site on the skin of a human patient a low sensitizing dose of an
immunomodulating gel composition followed by a subsequent
administration to a second site on the skin of the patient a
challenge dose of the immunomodulating gel composition, wherein the
composition comprises diphenylcyclopropenone (DPCP).
[0015] In one embodiment, the disease or disorder associated with
human papilloma virus infection is selected from the group
consisting of common warts, plantar warts, inguinal warts, venereal
warts, and any combination thereof.
[0016] In one embodiment, the low sensitizing dose is in the range
of about 0.4% DPCP to about 0.6% DPCP, and wherein the challenge
dose is in the range of about 0.04% DPCP to about 0.1% DPCP.
[0017] In one embodiment, the low sensitizing dose is about 0.4%
DPCP, and wherein the challenge dose is about 0.04% DPCP.
[0018] In one embodiment, the subsequent challenge dose is
administered to the skin of the patient daily.
[0019] In one embodiment, the subsequent challenge dose is
administered to the skin of the patient every other day.
[0020] In one embodiment, the subsequent challenge dose is
administered to the skin of the patient biweekly.
[0021] In one embodiment, the subsequent challenge dose is
administered to the skin of the patient weekly.
[0022] In one embodiment, the immunomodulating gel composition
further comprises a gel delivery system comprising: a) a first
co-solvent comprising a non-ionic surfactant, b) a second
co-solvent comprising an alcoholic ester, and c) a gelling
agent.
[0023] In one embodiment, the first co-solvent is selected from the
group consisting of polyoxyethylene (20) monoleate, polyoxyethylene
(20) sorbitan monooleate, palmitate and stearate, and wherein the
second co-solvent is selected from the group consisting of
isopropyl myristate and isopropyl palmitate, and wherein the
gelling agent is polyoxyl 40 stearate.
[0024] The invention also provides a method of treating cancer in a
human patient. The method comprises administering to a first site
on the skin of a human patient a low sensitizing dose of an
immunomodulating gel composition followed by a subsequent
administration to a second site on the skin of the patient a
challenge dose of the immunomodulating gel composition, wherein the
composition comprises DPCP.
[0025] In one embodiment, the cancer is selected from the group
consisting of melanoma, cutaneous melanoma, Merkel cell carcinoma,
basal cell carcinoma and it's subtype basal cell nevus syndrome,
squamous cell carcinoma and it's subtype Bowen's Disease, actinic
keratosis, and cutaneous T cell lymphoma and it's subtype mycosis
fungoides.
[0026] In one embodiment, the low sensitizing dose is in the range
of about 0.4% DPCP to about 0.6% DPCPC, and wherein the challenge
dose is in the range of about 0.04% DPCP to about 0.1% DPCP.
[0027] In one embodiment, the low sensitizing dose is about 0.4%
DPCP, and wherein the challenge dose is about 0.04% DPCP.
[0028] In one embodiment, the subsequent challenge dose is
administered to the skin of the patient daily.
[0029] In one embodiment, the subsequent challenge dose is
administered to the skin of the patient every other day.
[0030] In one embodiment, the subsequent challenge dose is
administered to the skin of the patient biweekly.
[0031] In one embodiment, the subsequent challenge dose is
administered to the skin of the patient weekly.
[0032] In one embodiment, the immunomodulating gel composition
further comprises a gel delivery system comprising: a) a first
co-solvent comprising a non-ionic surfactant, b) a second
co-solvent comprising an alcoholic ester, and c) a gelling
agent.
[0033] In one embodiment, the first co-solvent is selected from the
group consisting of polyoxyethylene (20) monoleate, polyoxyethylene
(20) sorbitan monooleate, palmitate and stearate, and wherein the
second co-solvent is selected from the group consisting of
isopropyl myristate and isopropyl palmitate, and wherein the
gelling agent is polyoxyl 40 stearate.
[0034] The present invention provides a method of treating a
disease or disorder associated with human papilloma virus infection
in a human patient comprises administering to the skin of the human
patient a sensitizing dose of about 0.4% DPCP followed by a
challenge dose of about 0.04% DPCP at 14 days and then weekly
challenge doses of about 0.04% DPCP for at least 6 weeks.
[0035] The present invention provides a method of treating a
disease or disorder associated with human papilloma virus infection
in a human patient comprising administering to the skin of the
human patient a sensitizing dose of about 0.4% DPCP followed by a
challenge dose of about 0.04% DPCP at 14 days and then biweekly
challenge doses of about 0.04% DPCP for at least 6 weeks.
[0036] The present invention provides a method of treating skin
cancer in a human patient comprising administering to the skin of
the human patient a sensitizing dose of about 0.4% DPCP followed by
a challenge dose of DPCP in the range of about 0.04% to about 0.1%
at 14 days and then biweekly challenge doses of DPCP in the range
of about 0.04% to about 0.1% for a sufficient amount of time.
[0037] The present invention provides a method of treating skin
cancer in a human patient comprising administering to the skin of
the human patient a sensitizing dose of about 0.4% DPCP followed by
a challenge dose of about 0.04% DPCP at 14 days and then biweekly
challenge doses of about 0.04% DPCP for a sufficient amount of
time.
[0038] The present invention provides a method of enhancing an
immune response in a human patient comprising administering to a
first site on the skin of the human patient a low sensitizing dose
of an immunomodulating gel composition followed by a subsequent
administration to a second site on the skin of the patient a
challenge dose of the immunomodulating gel composition, wherein the
composition comprises DPCP.
DETAILED DESCRIPTION OF THE INVENTION
[0039] The present invention provides a method of sensitizing a
subject to a therapeutic modality, comprising administering a
sensitizing dose of an immunomodulating gel composition in
combination with an effective challenge dose of the
immunomodulating gel composition to the subject. Preferably, the
immunomodulating gel composition comprises Diphenylcyclopropenone
(DPCP). For example, the invention provides a method of sensitizing
a subject by administering a sensitizing dose of DPCP at a first
site on the subject followed by administration of a challenge dose
of DPCP at a second site on the subject.
[0040] The present invention is based on the discovery that a low
sensitizing dose of about 0.4% DPCP gel compared to the standard
sensitizing dose of 2.0% DPCP used in the art prevents the subject
from becoming overly hypersensitive to the challenge dose.
Sensitizing a subject according to prior art methods at a higher
dose of about 2.0% DPCP corresponds to a challenge dose of about
0.002% DPCP because a 2.0% sensitizing dose of DPCP is in essence
an "overdose". Thus, prior art sensitizing dose of about 2.0% DPCP
results in the subject becoming overly hypersensitive to DPCP and
therefore requiring the very low challenge dose of about 0.002%
DPCP and in some cases even lower. Contrary to prior art methods,
the present invention allows for a higher challenge dose of about
0.04% DPCP compared to the prior art challenge dose of 0.002% DPCP
because the relative low sensitizing dose of about 0.4% DPCP
compared to 2.0% DPCP does not overly hypersensitize the subject to
the challenge dose.
[0041] Accordingly, in one embodiment, the present invention
relates to a type of topical immunotherapy treatment regimen
comprising administering a low sensitizing dose of to a sensitizing
site on a subject followed by administration of a treatment dose or
otherwise known as a challenge dose of DPCP to a target site on the
subject. Preferably, the topical immunotherapy treatment regimen of
the invention is useful for the treatment of warts as well as
cancer, preferably skin cancer.
[0042] In another embodiment, the invention provides a treatment
regimen against papilloma virus infection, such as warts (common,
plantar and genital warts), using a low dose sensitizing amount of
about 0.4% DPCP gel compared to the standard sensitizing dose of
2.0% used in the art in combination with a higher challenge does of
about 0.04% DPCP gel compared to the standard challenge dose of
0.002% used in the art. This treatment regimen also provides a
therapy against cancer including, but is not limited to melanoma,
cutaneous melanoma, Merkel cell carcinoma, basal cell carcinoma and
it's subtype basal cell nevus syndrome, squamous cell carcinoma and
it's subtype Bowen's Disease, actinic keratosis, and cutaneous T
cell lymphoma and it's subtype mycosis fungoides.
[0043] The present invention is based on the discovery that a low
sensitizing dose of about 0.4% DPCP effectively sensitizes the
subject wherein repeated application of a challenge dose of about
0.04% DPCP to the skin enhances the immune response to DPCP. In one
embodiment, repeated application of the challenge dose of DPCP
enhances production of cytokines from immune cells. In another
embodiment, repeated application of the challenge dose of DPCP
enhances immune cells to aggregate in the area of application.
These immune cells, along with other cells found in the skin, are
responsible for the production of anti-viral antibodies and
cell-mediated immunity against the agent causing the disease. The
immune response induced by the low sensitizing and corresponding
challenge dose of DPCP according to the invention is believed to be
responsible for the resolution of the disease.
[0044] Advantages of the treatment regimen of the invention include
the ease of application, relatively low cost, safety, specificity
and, most importantly, the painless nature of the treatment.
Another advantage is that the relative low sensitizing dose of DPCP
of the invention compared to the standard prior art sensitizing
dose of 2.0% DPCP allows for a logarithmic increase in the
challenge dose compared to the standard challenge dose associated
with a sensitizing dose of about 2.0%. Another advantage is that
the relative low sensitizing dose of DPCP of the invention allows
for more frequent administration of the challenge dose to the
subject. For example, the challenge dose can be administered daily,
every other day, or biweekly to the subject.
[0045] The present invention provides a method of sensitizing a
subject to a therapeutic modality, comprising administering a
sensitizing dose of immunomodulating gel composition in combination
with an effective challenge dose of the immunomodulating gel
composition to the subject. Preferably, the immunomodulating gel
composition comprises DPCP. For example, the invention provides a
method of sensitizing a subject by administering a sensitizing dose
of DPCP at a first site on the subject followed by administration
of a challenge dose of DPCP at a second site on the subject.
[0046] Accordingly, the invention provides a therapy against
papilloma virus infection, such as warts (common, plantar and
genital warts), using a low dose sensitizing amount of about 0.4%
DPCP gel and a challenge does of about 0.04% DPCP gel. The
invention also provides a therapy against cancer, preferably skin
cancer.
DEFINITIONS
[0047] As used herein, each of the following terms has the meaning
associated with it in this section.
[0048] The articles "a" and "an" are used herein to refer to one or
to more than one (i.e. to at least one) of the grammatical object
of the article. By way of example, "an element" means one element
or more than one element.
[0049] The term "about" will be understood by persons of ordinary
skill in the art and will vary to some extent on the context in
which it is used.
[0050] "Activation", as used herein, refers to the state of a T
cell that has been sufficiently stimulated to induce detectable
cellular proliferation. Activation can also be associated with
induced cytokine production, and detectable effector functions. The
term "activated T cells" refers to, among other things, T cells
that are undergoing cell division.
[0051] As used herein, to "alleviate" a disease means reducing the
severity of one or more symptoms of the disease.
[0052] The term "apoptosis," as used herein, means an active
process, involving the activation of a preexisting cellular
pathway, induced by an extracellular or intracellular signal,
causing the death of the cell. In particular, the cell death
involves nuclear fragmentation, chromatin condensation, and the
like, in a cell with an intact membrane.
[0053] An "apoptosis-inducing agent" refers to an agent that acts
to inhibit cancer-cell proliferation or tumor growth, at least in
part, by inducing apoptosis or programmed cell death in cancer
cells.
[0054] The term "autoimmune disease" as used herein is defined as a
disorder that results from an autoimmune response. An autoimmune
disease is the result of an inappropriate and excessive response to
a self-antigen. Examples of autoimmune diseases include but are not
limited to, Addision's disease, alopecia greata, ankylosing
spondylitis, autoimmune hepatitis, autoimmune parotitis, Crohn's
disease, diabetes (Type I), dystrophic epidermolysis bullosa,
epididymitis, glomerulonephritis, Graves' disease, Guillain-Barr
syndrome, Hashimoto's disease, hemolytic anemia, systemic lupus
erythematosus, multiple sclerosis, myasthenia gravis, pemphigus
vulgaris, psoriasis, rheumatic fever, rheumatoid arthritis,
sarcoidosis, scleroderma, Sjogren's syndrome,
spondyloarthropathies, thyroiditis, vasculitis, vitiligo, myxedema,
pernicious anemia, ulcerative colitis, among others.
[0055] The term "cancer" as used herein is defined as disease
characterized by the rapid and uncontrolled growth of aberrant
cells. Cancer cells can spread locally or through the bloodstream
and lymphatic system to other parts of the body. Examples of
various cancers include but are not limited to, breast cancer,
prostate cancer, ovarian cancer, cervical cancer, skin cancer,
pancreatic cancer, colorectal cancer, renal cancer, liver cancer,
brain cancer, lymphoma, leukemia, lung cancer and the like. In some
instances, hyperproliferative disorders are referred to as a type
of cancer including but not limited to primary or metastatic
melanoma, thymoma, lymphoma, sarcoma, lung cancer, liver cancer,
non-Hodgkin's lymphoma, Hodgkins lymphoma, leukemias, uterine
cancer, cervical cancer, bladder cancer, kidney cancer and
adenocarcinomas such as breast cancer, prostate cancer, ovarian
cancer, pancreatic cancer, and the like.
[0056] The term "cutaneous lymphoma" refers to tumors essentially
consisting of dilated lymph channels of various sizes lined by
normal lymph endothelium that may be present only in the skin, but
frequently extend into subcutaneous fat and even muscle. The more
frequent cutaneous lymphomas are cutaneous T-cell lymphomas and
lymphangiomas.
[0057] A "disease" is a state of health of an animal wherein the
animal cannot maintain homeostasis, and wherein if the disease is
not ameliorated, the animal's health continues to deteriorate. In
contrast, a "disorder" in an animal is a state of health in which
the animal is able to maintain homeostasis, but in which the
animal's state of health is less favorable than it would be in the
absence of the disorder. Left untreated, a disorder does not
necessarily cause a further decrease in the animal's state of
health.
[0058] "An effective amount" as used herein, means an amount that
provides a therapeutic or prophylactic benefit.
[0059] The term "enhancing an immune response" means that the
method of the invention evokes and/or enhances any response of the
animal's immune system, including of either a cell-mediated (i.e.
cytotoxic T lymphocyte mediated) or humoral (i.e. antibody
mediated) response. These immune responses can be assessed by
number of in vitro or in vivo assays well known to those skilled in
the art including, but not limited to, cytotoxic T lymphocyte
assays, productions of cytokines, regression of tumors, survival of
tumor bearing animals, and antibody assays.
[0060] The term "fibrosis" relates to and includes the excessive
formation or development of fibrous connective tissue in an organ
or tissue as a reactive or repairing process, in opposition to the
formation of fibrous tissue as a normal constituent of an organ or
tissue. Fibrosis includes but is not limited to endomyocardial
fibrosis, idiopathic pulmonary fibrosis, emphysema, pulmonary
fibrosis (leading to chronic obstructive pulmonary disease),
Peyronie's disease, scleroderma, diffuse parenchymal lung disease,
cheloids, mediastinal fibrosis, progressive massive fibrosis,
proliferative fibrosis, neoplastic fibrosis, renal interstitial
fibrosis, hepatic fibrosis, organ fibrosis, surgical scars or
burns.
[0061] By the term "immune reaction," as used herein, is meant the
detectable result of stimulating and/or activating an immune
cell.
[0062] "Immune response," as the term is used herein, means a
process that results in the activation and/or invocation of an
effector function in the T cells, B cells, natural killer (NK)
cells, and/or antigen-presenting cells (APCs). Thus, an immune
response, as would be understood by the skilled artisan, includes,
but is not limited to, any detectable antigen-specific or
allogeneic activation of a helper T cell or cytotoxic T cell
response, production of antibodies, T cell-mediated activation of
allergic reactions, and the like.
[0063] "Immune cell," as the term is used herein, means any cell
involved in the mounting of an immune response. Such cells include,
but are not limited to, T cells, B cells, NK cells,
antigen-presenting cells (e.g., dendritic cells and macrophages),
monocytes, neutrophils, eosinophils, basophils, and the like.
[0064] The term "inhibit" is used in reference to a baseline level
of a specified activity (e.g., tumor growth or metastasis), which
can be the level of the specified activity in the absence of an
agent that has the inhibiting activity.
[0065] An agent is said to "inhibit the proliferation of cancer
cells" if the proliferation of cells in the presence of the agent
is less than that observed in the absence of the agent. That is,
proliferation of the cells is either slowed or halted in the
presence of the agent. Inhibition of cancer-cell proliferation may
be evidenced, for example, by reduction in the number of cells or
rate of expansion of cells, reduction in tumor mass or the rate of
tumor growth, or increase in survival rate of a subject being
treated.
[0066] The term "Merkel cell carcinoma (MCC)" refers to a
neuroendocrine cancer that typically presents as a fast growing
unspecific nodule on sun-exposed skin.
[0067] By the term "modulating" an immune response, as used herein,
is meant mediating a detectable increase or decrease in the level
of an immune response in a mammal compared with the level of an
immune response in the mammal in the absence of a treatment or
compound, and/or compared with the level of an immune response in
an otherwise identical but untreated mammal. The term encompasses
perturbing and/or affecting a native signal or response thereby
mediating a beneficial therapeutic response in a mammal,
preferably, a human.
[0068] The term "patient" relates to animals, preferably mammals,
more preferably human beings, and includes men and women, and
children and adults.
[0069] The term "sarcomas" refers to tumors of mesodermal origin
affecting connective tissue of the skin, subcutaneous tissues or
fascial sheaths. The more representative sarcomas affecting the
skin are epithelioid cell sarcoma and angiosarcoma.
[0070] The term "skin cancer" is used broadly to refer to the
malignant proliferation of any cells of the skin. The term "skin
cancer" relates to and includes lentigo maligna, melanoma,
keratoacanthoma, basal cell carcinoma (BCC), squamous cell
carcinoma (SCC), Merkel cell carcinoma (MCC), sarcoma,
angiosarcoma, cutaneous lymphoma, sweat gland carcinoma and
sebaceous gland carcinoma. Melanoma is a form of skin cancer. In
particular, "melanoma" refers to a malignant proliferation of
melanocytes. The first phase of most melanomas is termed the radial
growth phase (RGP) and is along the dermoepidermal junction and
within the dermis. In the vertical growth phase (VGP) growth down
through the epidermis brings the malignant melanocytes into contact
with lymphatic tissue and capillaries, leading to metastasis.
[0071] "Sensitizing" a mammal to an agent, as used herein, refers
to the act of enhancing the immune sensitivity of a mammal to an
agent.
[0072] A "sensitizing effective amount" of the immunomodulating gel
composition of the invention means that amount which, when
administered to a mammal, especially a human, for treating a
disease or condition, is sufficient to sensitize the mammal.
[0073] The term "subject" as used herein refers to any individual
or patient to which the subject methods are performed. Generally
the subject is human, although as will be appreciated by those in
the art, the subject may be an animal. Thus other animals,
including mammals such as rodents (including mice, rats, hamsters
and guinea pigs), cats, dogs, rabbits, farm animals including cows,
horses, goats, sheep, pigs, etc., and primates (including monkeys,
chimpanzees, orangutans and gorillas) are included within the
definition of subject.
[0074] The term "therapeutically effective amount" refers to the
amount of the subject compound that will elicit the biological or
medical response of a tissue, system, animal or human that is being
sought by the researcher, veterinarian, medical doctor or other
clinician. The term "therapeutically effective amount" includes
that amount of a compound that, when administered, is sufficient to
prevent development of, or alleviate to some extent, one or more of
the symptoms of the condition or disorder being treated. The
therapeutically effective amount will vary depending on the
compound, the disease and its severity and the age, weight, etc.,
of the mammal to be treated.
[0075] To "treat" a disease as the term is used herein, means to
reduce the frequency of the disease or disorder reducing the
frequency with which a symptom of the one or more symptoms disease
or disorder is experienced by an animal. The terms "treat",
"treating" or "therapeutic", as used herein, also mean a treatment
which decreases the likelihood that the subject administered such
treatment will manifest symptoms of disease or other
conditions.
[0076] As used herein, the term "ameliorating" or "treating" means
that the clinical signs and/or the symptoms associated with the
cancer or melanoma are lessened as a result of the actions
performed. The signs or symptoms to be monitored will be
characteristic of a particular cancer or melanoma and will be well
known to the skilled clinician, as will the methods for monitoring
the signs and conditions. For example, the skilled clinician will
know that the size or rate of growth of a tumor can monitored using
a diagnostic imaging method typically used for the particular tumor
(e.g., using ultrasound or magnetic resonance image (MRI) to
monitor a tumor).
[0077] "Treating a papilloma virus infection" means alleviating or
eliminating the symptoms of a papilloma virus infection, or slowing
down the progress of a papilloma virus infection.
[0078] The term "T-helper" as used herein with reference to cells
indicates a sub-group of lymphocytes (a type of white blood cell or
leukocyte) including different cell types identifiable by a skilled
person. In particular, T-helper cell according to the present
disclosure include effector Th cells (such as Th1, Th2 and Th17).
These Th cells secrete cytokines, proteins or peptides that
stimulate or interact with other leukocytes.
[0079] Ranges: throughout this disclosure, various aspects of the
invention can be presented in a range format. It should be
understood that the description in range format is merely for
convenience and brevity and should not be construed as an
inflexible limitation on the scope of the invention. Accordingly,
the description of a range should be considered to have
specifically disclosed all the possible subranges as well as
individual numerical values within that range. For example,
description of a range such as from 1 to 6 should be considered to
have specifically disclosed subranges such as from 1 to 3, from 1
to 4, from 1 to 5, from 2 to 4, from 2 to 6, from 3 to 6 etc., as
well as individual numbers within that range, for example, 1, 2,
2.7, 3, 4, 5, 5.3, and 6. This applies regardless of the breadth of
the range.
DESCRIPTION
[0080] The present invention relates to methods and compositions
for sensitizing a mammal, preferably a human, to an
immunomodulating gel composition. In this manner, the invention
relates to a general method of sensitizing a mammal to an
immunomodulating gel composition whereby the subject's immune
system is sensitive to a challenge dose of the immunomodulating gel
composition. The mammal's sensitive immune response is effective in
treating a disease or disorder associated with an inefficient
immune response.
[0081] In one embodiment, the invention relates to methods and
compositions for sensitizing a mammal, preferably a human, to an
immunomodulating gel composition for the effective treatment of a
papilloma virus infection and skin cancer such as cutaneous
metastatic melanoma.
[0082] The present invention relates to a type of topical
immunotherapy treatment regimen comprising administering a low
sensitizing dose of DPCP to a target site followed by
administration of a treatment dose or otherwise known as a
challenge dose of DPCP to the target site for the treatment of
warts as well as skin cancer.
[0083] In some instances, administration of the sensitizing dose
induces a cutaneous immune response in the mammal prior to the
administration of the challenge dose of the DPCP gel to the target
site or nearby site. This type of immunotherapy is particularly
useful in treating papilloma virus infection including warts or
verrucae that are induced by or related to papilloma virus. This
type of immunotherapy is also particularly useful in treating
epithelial tumors such as cutaneous tumors.
[0084] Topical application of a low sensitizing dose of DPCP
according to the invention acts by elicitation of sensitivity to a
challenge dose at the target site. Preferably, the site of topical
application of the initial low sensitizing dose of DPCP is at a
different site than the target site for the challenge dose.
[0085] In one embodiment, the site for administering the low
sensitizing dose of DPCP on a subject is a different site from the
target site for which the challenge dose is administered.
Preferably, the site for administering the low sensitizing dose is
at or around a lymph node. Lymph nodes are distributed throughout
the body, with clusters found in the underarms, groin, neck, chest,
and abdomen.
[0086] A preferred site for administering the low sensitizing dose
of DPCP is at or around a lymphatic drainage area. The lymphatic
drainage system is organization into two separate and very unequal
drainage areas. These are the right and left drainage areas and
normally lymph does not drain across the invisible lines that
separate these areas. Structures within each area carry lymph to
its destination, which is to return to the circulatory system.
[0087] The right area drains lymph from the right side of the head
and neck, the right arm, and the upper right quadrant of the body.
Lymph from this area flows into the right lymphatic duct and this
duct empties the lymph into the right subclavian vein.
[0088] The left area drains lymph from the left side of the head
and neck, the left arm and the left upper quadrant, and the lower
trunk and both legs. The cisterna chyli temporarily stores lymph as
it moves upward from the lower areas of the body. The thoracic duct
transports lymph upward to the left lymphatic duct. The left
lymphatic duct empties the lymph into the left subclavian vein.
[0089] In one embodiment, a preferred site for administering the
low sensitizing dose to the subject is under the inner arm of the
subject. In another embodiment, the low sensitizing dose of DPCP
can be applied on the forearm of the subject. However, the
invention is not limited to the site of administering the low
sensitizing dose of DPCP. Rather, the low sensitizing site can be
anywhere at or near a lymph node, and preferably at or near a
lymphatic drain area.
[0090] The low sensitizing dose of about 0.4% DPCP gel according to
the present invention results in an unexpected finding from prior
art methods. The low sensitizing dose compared to prior art
sensitizing doses prevents the subject from becoming overly
hypersensitive to the challenge dose. That is, prior art methods
employ an initial sensitizing dose of about 2.0% with a
corresponding challenge dose of about 0.002%. It is believed that
the potency of the challenge dose is inversely proportional to the
sensitizing dose. Thus, sensitizing a mammal at a higher dose of
about 2.0% corresponds to a challenge dose of about 0.002% because
a 2.0% sensitizing dose is in essence an "overdose". Thus, prior
art sensitizing dose of about 2.0% results in the subject becoming
overly hypersensitive to DPCP and therefore requiring the very low
challenge dose of about 0.002% and in some cases even lower.
[0091] Routes of administration of the compounds of the invention
to a mammal include, but are not limited to, administration by
injection, including intravenous, intraperitoneal, intramuscular,
and subcutaneous injection, by transmucosal or transdermal
delivery, through topical applications, nasal spray, suppository
and the like or may be administered orally. The preferred route for
the low sensitizing dose and challenge dose of the invention is
topical administration.
[0092] The topical DPCP gel can be applied by dabbing a
cotton-tipped swab that has been saturated with the solution onto
the skin or mucous membrane at the desired site of application,
without repeated rubbing or spreading the solution over an extended
area. For both the sensitization and treatment applications, the
topical DPCP gel is preferably left on the skin for a period of
time before washing it off. In one embodiment, for both the
sensitization and treatment applications, the topical DPCP gel is
preferably left on the skin for about 1-72 hours, more preferably
2-60 hours, more preferably 3-48, more preferably 4-36 hours, most
preferably 8-24 hours.
[0093] In another embodiment, the DPCP gel is applied for both the
sensitization and treatment applications with a fixed volume
device, such as a micropipette, syringe, or microsyringe. This
allows application of a defined volume and therefore a defined
amount of the DPCP gel. That can be helpful to produce a more
predictable level of intensity of the immune response following
application of the DPCP gel. Preferably, the DPCP gel is applied to
the target site such as the lesion site without the gel spreading
or running to non-target areas.
Composition
[0094] In one embodiment, the immunomodulating gel composition of
the invention is a unique non-flowable gel composition that is
useful for direct topical application of a delayed type contact
sensitizer hapten in an anhydrous solubilized drug delivery system.
The immunomodulating gel composition of the invention can penetrate
the keratinized epithelium of human papilloma virus infections on
the skin to reach the antigen presenting cells in the dermis. In
this regard, see for example, U.S. Patent Application Publication
No. 20060211766 (Kaplan et al.) for immunomodulating gel
compositions for treating human papilloma virus infection. The
extensive disclosure provided in US20060211766 is incorporated by
reference as if set forth in its entirety herein.
[0095] In one embodiment, the gel composition comprises 1) a
delayed type contact sensitizer hapten; and 2) a gel delivery
system. The gel delivery system comprises a first co-solvent
comprising a non-ionic surfactant, a second co-solvent comprising
an alcoholic ester, and a gelling agent. Preferably, the gel
delivery system is anhydrous, non-volatile, and non-irritating. In
some instances, the gel delivery system is non-flowable to be
retained on the warts surface and the gel is uniquely formulated
with surfactants and emollients so as to be able to penetrate the
keratinized epithelium of warts surfaces to provide therapeutically
effective anti-viral activity.
[0096] In one embodiment, the delayed type contact sensitizer
hapten is selected from the group consisting of squaric acid
dibutylester, diphenylcyclopropenone, dinitrochlorobenzene,
dinitrofluorobenzene, exanolone, paraphenylenediamine and
urishiol.
[0097] In another embodiment, the first co-solvent is selected from
the group consisting of polyoxyethylene (20) monoleate,
polyoxyethylene (20) sorbitan monooleate palmitate and
stearate.
[0098] In yet another embodiment, the second co-solvent includes
isopropyl myristate or isopropyl palmitate.
[0099] In a further embodiment, the gelling agent is polyoxyl 40
stearate.
[0100] In one embodiment, the gel composition of the invention
comprises diphenylcyclopropenone, butylated hydroxytolunene,
polysorbate 80, and isopropyl myristate.
[0101] In yet another embodiment, the composition of the invention
is useful for the treatment warts. In another embodiment, the
composition of the invention is useful for the treatment of
neoplastic diseases, such as those diseases caused by melanocytes
and melanocytic nevus cells. The invention comprises the
administration of an initial low sensitizing dose of about 0.4%
DPCP gel at a target site followed by a challenge does of about
0.04% DPCP gel to the target site.
[0102] For administration of the composition of the invention, the
composition can be suspended in any pharmaceutically acceptable
carrier, for example, sterile water or a buffered aqueous carrier,
such as glycerol, water, saline, ethanol and other pharmaceutically
acceptable salt solutions such as phosphates and salts of organic
acids. Examples of these and other pharmaceutically acceptable
carriers are described in Remington's Pharmaceutical Sciences
(1991, Mack Publication Co., New Jersey), the disclosure of which
is incorporated by reference as if set forth in its entirety
herein.
[0103] The pharmaceutical compositions may be prepared, packaged,
or sold in the form of a sterile injectable aqueous or oily
suspension or solution. This suspension or solution may be
formulated according to the known art, and may comprise, in
addition to the active ingredient, additional ingredients such as
dispersing agents, wetting agents, or suspending agents described
herein. Such sterile injectable formulations may be prepared using
a non-toxic parenterally-acceptable diluent or solvent, such as
water or 1,3-butane dial, for example. Other acceptable diluents
and solvents include, but are not limited to, Ringer's solution,
isotonic sodium chloride solution, and fixed oils such as synthetic
mono- or di-glycerides.
[0104] The pharmaceutical compositions described herein can be
prepared alone, in a form suitable for administration to a subject,
or the pharmaceutical composition may comprise the active
ingredient and one or more pharmaceutically acceptable carriers,
one or more additional ingredients, or some combination of these.
The active ingredient may be present in the pharmaceutical
composition in the form of a physiologically acceptable ester or
salt, such as in combination with a physiologically acceptable
cation or anion, as is well known in the art.
[0105] Although the descriptions of pharmaceutical compositions
provided herein are principally directed to pharmaceutical
compositions that are suitable for ethical administration to
humans, it will be understood by the skilled artisan that such
compositions are generally suitable for administration to animals
of all sorts. Modification of pharmaceutical compositions suitable
for administration to humans in order to render the compositions
suitable for administration to various animals is well understood,
and the ordinarily skilled veterinary pharmacologist can design and
perform such modification with merely ordinary, if any,
experimentation. Subjects to which administration of the
pharmaceutical compositions of the invention is contemplated
include, but are not limited to, humans and other primates, mammals
including commercially relevant mammals such as cattle, pigs,
horses, sheep, cats, and dogs.
[0106] Formulations suitable for topical administration include,
but are not limited to, liquid or semi-liquid preparations such as
liniments, lotions, oil-in-water or water-in-oil emulsions such as
creams, ointments or pastes, and solutions or suspensions.
Topically-administrable formulations may, for example, comprise
from about 0.1% to about 10% (w/w) active ingredient, although the
concentration of the active ingredient may be as high as the
solubility limit of the active ingredient in the solvent.
Formulations for topical administration may further comprise one or
more of the additional ingredients described herein.
Treatment of Warts
[0107] In one embodiment, the present invention relates to methods
and compositions for sensitizing mammals, preferably humans, to
treat human papilloma virus (HPV) infections. In one embodiment,
the invention provides methods and compositions for treating
diseases or disorders associated with HPV infection. In some
instances, the disease or disorder is caused by HPV Infection.
[0108] The methods and compositions described herein can be used to
treat diseases and conditions caused by HPV infection, which can be
the result of clinical or sub-clinical papillomavirus infections.
Such diseases and conditions, herein sometimes called "HPV
associated disorders", include but not limited to epithelial
malignancies, skin cancer (non-melanoma or melanoma), anogenital
malignancies such as cervical cancer, HPV associated precancerous
lesions, anal carcinoma, malignant lesions, benign lesions,
papillomacarcinomas, papilloadenocystomas, papilloma neuropathicum,
papillomatosis, cutaneous and mucosal papillomas, condylomas,
fibroblastic tumors, and other pathological conditions associated
with papillomavirus.
[0109] In some instances, the methods and compositions of the
invention described herein can be used to treat warts caused by HPV
infection including but not limited to common warts (verruca
vulgaris), for example, palmar, plantar, and periungual warts; flat
and filiform warts; anal, oral, pharyngeal, laryngeal, and tongue
papillomas; and venereal warts (condyloma accuminata), also known
as genital warts (for example, penile, vulvar, vaginal and cervical
warts), which are one of the most serious manifestations of HPV
infection. HPV DNA can be found in all grades of cervical
intraepithelial neoplasia (CIN I-III), and a specific subset of HPV
types can be found in carcinoma in situ of the cervix.
Consequently, women with genital warts, containing specific HPV
types, are considered to be at high risk for the development of
cervical cancer.
[0110] HPV infection has been shown to be associated with cancer.
Squamous cell carcinoma has been shown to contain HPV-16 (Baker et
al., 1997 Dermatologic Clinics 1997 15: 331-340). Dysplastic
periungual papillomas have been shown to have HPV-57.
Epidermodysplasia verruciformis is a genetic condition of altered
cell-mediated immunity in which affected individuals develop
chronic HPV infection and squamous cell carcinoma. There are other
states of immunosuppression, both congenital and acquired, that
lend to heightened HPV infection and HPV-associated malignancies
(Johnson et al., 1999 Consultant 39: 253-266). The risk of
malignant transformation may or may not be decreased with
treatment. At a minimum, treatment to decrease the spread of HPV
may prevent others from developing a cancer promoting
infection.
[0111] Contrary to prior art methods, the invention is based on the
unexpected finding that a low sensitizing dose of about 0.4% DPCP
gel allows for a higher challenge dose of about 0.04% DPCP gel.
This treatment regimen is an improvement to prior art regimens
because the treatment regimen of the invention allows for a higher
challenge dose resulting in an effective treatment of papilloma
infection, such as warts, having no severe adverse reactions at the
application site. In this regard, the treatment regimen of the
invention provides a benefit to other prior art regiments because
the higher challenge dose of about 0.04% DPCP gel can be tolerated
in the subjects sensitized with a low sensitizing dose where
otherwise such a higher challenge dose would result in adverse
effects when using a relative high sensitizing dose of 2.0% DPCP
gel. The treatment regimen of the invention also allows for more
frequent challenge dosing of DPCP to the subject.
[0112] In one embodiment, the present invention relates to a method
of treating a papilloma virus infection in a mammal comprising
administering an effective amount of a pharmaceutical composition
containing a low sensitizing dose of about 0.4% DPCP gel at a first
sensitizing site followed by administering an effective amount of a
pharmaceutical composition containing a challenge does of about
0.04% DPCP gel at a second target site.
[0113] The treatment regimen of the invention also provides an
advantage to prior art regiments because the low sensitizing dose
in combination with a higher challenge does allows for desirable
clearance rate of warts in a short amount of time. In some
instances, the treatment regimen of the invention can clear warts
from a subject in about 3 weeks. In other instances, the treatment
regimen of the invention can clear warts from a subject in about 4
weeks. In other instances, the treatment regimen of the invention
can clear warts from a subject in about 5 weeks. In other
instances, the treatment regimen of the invention can clear warts
from a subject in about 6 weeks. In other instances, the treatment
regimen of the invention can clear warts from a subject in about 7
weeks. In other instances, the treatment regimen of the invention
can clear warts from a subject in about 8 weeks. In other
instances, the treatment regimen of the invention can clear warts
from a subject in about 9 weeks or more.
[0114] In one embodiment, the treatment regimen for clearance of
warts comprises the initial low sensitizing dose of about 0.04%
DPCP gel at the target site and a challenge does approximately 14
days following the initial sensitization and weekly challenge doses
of about 0.04% DPCP gel thereafter for various periods. In some
instances, the initial challenge dose can be any time after the
initial sensitizing dose. For example, the initial challenge dose
can be from about 1 through 25 days following the initial
sensitizing doses. In another embodiment, the interval of challenge
doses can be weekly, biweekly, or every other day. In other
embodiments, the days between challenge doses can be 1, 2, 3, 4, 5,
6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, or more
days.
[0115] A suitable low sensitizing dose of DPCP of the invention may
be any dose lower than 2.0% DPCP or otherwise the usual sensitizing
dose of DPCP currently used in the art. Preferably, the low
sensitizing dose of DPCP of the invention is a fraction of about
1-99% of the prior art sensitizing dose of 2.0% DPCP, preferably a
fraction of about 10-90% of prior art sensitizing dose of 2.0%
DPCP, more preferably a fraction about 20% of prior art sensitizing
dose of 2.0% DPCP, yet more preferably a fraction about 25% of
prior art sensitizing dose of 2.0% DPCP, yet more preferably a
fraction of about 30% of prior art sensitizing dose of 2.0% DPCP,
yet more preferably a fraction of about 40% of prior art
sensitizing dose of 2.0% DPCP, yet more preferably a fraction of
about 50% of prior art sensitizing dose of 2.0% DPCP, yet more
preferably a fraction of about 60% of prior art sensitizing dose of
2.0% DPCP, yet more preferably a fraction of about 70% of prior art
sensitizing dose of 2.0% DPCP, yet more preferably a fraction of
about 80% of prior art sensitizing dose of 2.0% DPCP, yet more
preferably a fraction of about 90% of prior art sensitizing dose of
2.0% DPCP.
[0116] In one embodiment, the low sensitizing dose of DPCP of the
invention is within the range of about 0.01% to about 0.19%,
preferably within the range of about 0.2% to about 0.1%, more
preferably within the range of about 0.15% to about 0.1%, and more
preferably within the range of about 0.2% to about 0.8%, more
preferably within the range of about 0.3% to about 0.7%, and most
preferably within the range of about 0.4% to about 0.6%.
Preferably, the low sensitizing dose of DPCP of the invention is
about 0.4% DPCP.
[0117] A suitable challenge dose of DPCP may be any dose higher
than 0.002% or otherwise the usual challenge dose of DPCP
corresponding to the usual sensitizing dose of DPCP used in the
art. Preferably, the higher challenge dose of DPCP of the invention
is about 1-fold, 2-fold, 3-fold, 4-fold, 5-fold, 6-fold, 7-fold,
8-fold, 9-fold, 10-fold, 20-fold, 100-fold, or more, including any
integer in between, of the prior art challenge dose of 0.002%.
[0118] In one embodiment, the challenge dose of DPCP is within the
range of about 0.002% to about 0.2%, preferably within the range of
about 0.01% to about 0.15%, more preferably within the range of
about 0.015% to about 0.1%, and more preferably within the range of
about 0.02% to about 0.5%, more preferably within the range of
about 0.03% to about 0.25%, and most preferably within the range of
about 0.04% to about 0.1%. Preferably, the higher challenge dose of
DPCP is about 0.04% DPCP.
Treatment of Skin Cancer
[0119] The present invention relates to immunotherapy of skin
cancer, particularly cancers that are induced by infectious agents,
particularly viruses, and particularly papilloma viruses.
[0120] The present invention also relates to methods and
compositions for sensitizing a mammal, preferably a human, to treat
a cancer such that a lower dosage of a compound directed against
the cancer becomes more effective. Preferably, the cancer is skin
cancer. A cancer may belong to any of a group of cancers which have
been described elsewhere herein. An example of such a cancer
includes, but is not limited to, melanoma, squamous cell carcinoma,
basal cell carcinoma, and cutaneous T cell lymphoma.
[0121] The invention provides a treatment regimen comprising a low
sensitizing dose of about 0.4% DPCP gel followed by a challenge
dose of about 0.04% DPCP gel. This treatment regimen is an
improvement to prior art regimens because the treatment regimen of
the invention allows for a higher challenge dose resulting in an
effective reduction of tumor growth having no severe adverse
reactions at the application site. In this regard, the treatment
regimen of the invention provides a benefit to other prior art
regiments because the higher challenge dose of about 0.04% DPCP gel
can be tolerated in the subjects sensitized with a low sensitizing
dose where otherwise such a higher challenge dose would result in
adverse effects when using a relative high sensitizing dose of 2.0%
DPCP gel.
[0122] The treatment regimen of the invention also provides an
advantage to prior art regiments because the low sensitizing dose
in combination with a higher challenge does allows for desirable
reduction in tumor cell growth in a short amount of time. In some
instances, the treatment regimen of the invention can inhibit tumor
cell growth from a subject in about 30 weeks. In other instances,
the treatment regimen of the invention can inhibit tumor cell
growth from a subject in about 40 weeks. In other instances, the
treatment regimen of the invention can inhibit tumor cell growth
from a subject in about 50 weeks. In other instances, the treatment
regimen of the invention can inhibit tumor cell growth from a
subject in about 60 weeks. In other instances, the treatment
regimen of the invention can inhibit tumor cell growth from a
subject in about 70 weeks. In other instances, the treatment
regimen of the invention can inhibit tumor cell growth from a
subject in about 80 weeks. In other instances, the treatment
regimen of the invention can inhibit tumor cell growth from a
subject in about 90 weeks or more.
[0123] In one embodiment, the treatment regimen for reduction in
tumor cell growth comprises the initial low sensitizing dose of
about 0.04% DPCP gel at the target site and a challenge does
approximately 14 days following the initial sensitization and
weekly challenge doses of about 0.04% DPCP gel thereafter for
various periods. In some instances, the initial challenge dose can
be any time after the initial sensitizing dose. For example, the
initial challenge dose can be from about 1 through 25 days
following the initial sensitizing doses. In another embodiment, the
interval of challenge doses can be daily, every other day, weekly
or biweekly. In other embodiments, the days between challenge doses
can be 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,
18, 19, 20, or more days.
[0124] A suitable low sensitizing dose of DPCP of the invention may
be any dose lower than 2.0% DPCP or otherwise the usual sensitizing
dose of DPCP currently used in the art. Preferably, the low
sensitizing dose of DPCP of the invention is a fraction of about
1-99% of the prior art sensitizing dose of 2.0% DPCP, preferably a
fraction of about 10-90% of prior art sensitizing dose of 2.0%
DPCP, more preferably a fraction about 20% of prior art sensitizing
dose of 2.0% DPCP, yet more preferably a fraction about 25% of
prior art sensitizing dose of 2.0% DPCP, yet more preferably a
fraction of about 30% of prior art sensitizing dose of 2.0% DPCP,
yet more preferably a fraction of about 40% of prior art
sensitizing dose of 2.0% DPCP, yet more preferably a fraction of
about 50% of prior art sensitizing dose of 2.0% DPCP, yet more
preferably a fraction of about 60% of prior art sensitizing dose of
2.0% DPCP, yet more preferably a fraction of about 70% of prior art
sensitizing dose of 2.0% DPCP, yet more preferably a fraction of
about 80% of prior art sensitizing dose of 2.0% DPCP, yet more
preferably a fraction of about 90% of prior art sensitizing dose of
2.0% DPCP.
[0125] In one embodiment, the low sensitizing dose of DPCP of the
invention is within the range of about 0.01% to about 0.19%,
preferably within the range of about 0.2% to about 0.1%, more
preferably within the range of about 0.15% to about 0.1%, and more
preferably within the range of about 0.2% to about 0.8%, more
preferably within the range of about 0.3% to about 0.7%, and most
preferably within the range of about 0.4% to about 0.6%.
Preferably, the low sensitizing dose of DPCP of the invention is
about 0.4% DPCP.
[0126] Suitable challenge dose of DPCP may be any dose higher than
0.002% or otherwise the usual challenge dose of DPCP corresponding
to the usual sensitizing dose of DPCP used in the art. Preferably,
the higher challenge dose of DPCP of the invention is about 1-fold,
2-fold, 3-fold, 4-fold, 5-fold, 6-fold, 7-fold, 8-fold, 9-fold,
10-fold, 20-fold, 100-fold, or more, including any integer in
between, of the prior art challenge dose of 0.002%.
[0127] In one embodiment, the challenge dose of DPCP is within the
range of about 0.002% to about 0.5%, preferably within the range of
about 0.01% to about 0.4%, more preferably within the range of
about 0.015% to about 0.3%, and more preferably within the range of
about 0.02% to about 0.2%, more preferably within the range of
about 0.03% to about 0.15%, and most preferably within the range of
about 0.04% to about 0.1%.
[0128] The frequency of administration of the challenge dose of
DPCP can be any frequency that reduces the progression rate of skin
cancer without producing significant toxicity to the mammal. For
example, the frequency of administration can be from about four
times a day to about once every other month, or from about once a
day to about once a month, or from about one every other day to
about once a week. In addition, the frequency of administration can
remain constant or can be variable during the duration of
treatment. A course of treatment with the challenge dose can
include rest periods. For example, the challenge dose can be
administered for five days followed by a nine-day rest period, and
such a regimen can be repeated multiple times. As with the
effective amount, various factors can influence the actual
frequency of administration used for a particular application. For
example, the effective amount, duration of treatment, use of
multiple treatment agents, and severity of the skin cancer may
require an increase or decrease in administration frequency.
[0129] An effective duration for administering a composition
provided herein can be any duration that reduces the progression
rate of skin cancer without producing significant toxicity to the
mammal. Thus, the effective duration can vary from several days to
several weeks, months, or years. In general, the effective duration
for the treatment of skin cancer can range in duration from several
days to several months. In some cases, an effective duration can be
for as long as an individual mammal is alive. Multiple factors can
influence the actual effective duration used for a particular
treatment. For example, an effective duration can vary with the
frequency of administration, effective amount, use of multiple
treatment agents, route of administration, and severity of the skin
cancer.
[0130] In some instances, the methods and compositions of the
invention described herein can be used to treat cancer, preferably
skin cancer. Non-limiting examples of cancers include but are not
limited to, melanoma, cutaneous melanoma, Merkel cell carcinoma,
basal cell carcinoma and it's subtype basal cell nevus syndrome,
squamous cell carcinoma and it's subtype Bowen's Disease, actinic
keratosis, and cutaneous T cell lymphoma and it's subtype mycosis
fungoides.
[0131] The invention also provides compositions and methods of
sensitizing a mammal for cancer treatment. For example, the
compositions and methods of the present invention can be used in
the prevention and treatment of cancer in general or in the
treatment of cancer associated with viral replication. For example,
the compositions and methods of the invention can be used to treat
cutaneous metastatic melanoma.
[0132] In one embodiment, the present invention provides methods of
inhibiting growth and metastasis of melanoma. In another
embodiment, the invention provides methods of sensitizing melanoma
cells to apoptosis. In yet another embodiment, the invention
provides methods of treating a mammal having melanoma following a
treatment regimen comprising administration of a low sensitizing
dose of a DPCP gel followed by a challenge does of a DPCP gel to
the mammal.
[0133] In one embodiment, the invention provides a method for the
treatment of melanoma and diseases, in particular neoplastic
diseases, caused by melanocytes and melanocytic nevus cells
comprising direct topical administration of the DPCP gel on the
lesions comprising the cancerous cells. Topical administration may
take place directly on the skin, on healthy or normal skin or
preferably on, in or around lesions on or in the skin, i.e. on the
melanomas or nevi to be treated. The methods of the invention are
also applicable to treating pre-melanoma lesions, congenital
melanocytic nevi (e.g. Giant Hairy nevus), melanocytic nevi (e.g
atypical or dysplastic nevi), cellular blue nevus and Becker's
nevus, all of which are known to be capable of becoming
malignant.
[0134] Treatment of a melanoma may include the treatment of solid
tumors or the treatment of metastasis. Metastasis is a form of
cancer wherein the transformed or malignant cells travel and spread
the cancer from one site in the body to another. Cancer cells may
metastasize through the bloodstream, through the lymphatic system,
across body cavities, or any combination thereof. When melanomas
have spread to the lymph nodes, micrometastases in which malignancy
is only microscopic have a more favorable prognosis than
micrometastases. In some cases, micrometastases may only be
detected by special staining. If malignancy is only detectable by
polymerase chain reaction (PCR), the prognosis is better.
Macrometastases in which malignancy is clinically apparent (in some
cases cancer completely replaces a node) have a far worse
prognosis, and if nodes are matted or if there is extracapsular
extension, the prognosis is still worse.
[0135] In one aspect, the invention provides a method for
inhibiting melanoma growth comprising contacting the melanoma with
an effective amount of a first sensitizing dose of DPCP followed by
a challenge dose of DPCP. In another aspect, the invention provides
a method for inhibiting metastasis of melanoma comprising
contacting the melanoma with an effective amount of a first
sensitizing dose of DPCP followed by a challenge dose of DPCP. In
addition, a method for sensitizing melanoma cells to apoptosis
comprising contacting the cells with a first sensitizing dose of
DPCP followed by a challenge dose of DPCP is provided.
[0136] The current invention is based on the observation that an
initial low sensitizing dose of about 0.4% DPCP gel at a target
site provides an unexpected therapeutic effect for a challenge dose
of about 0.04% DPCP gel. Without wishing to be bound by any
particular theory, it is believed that the treatment regimen of the
invention comprising a low sensitizing dose followed by a challenge
dose serves to induce the immune system to attack the diseased
cell. For example, the Langerhans cells, dendritic cells in the
skin may be induced by the treatment regimen in a manner that pick
up antigens and process them into an 8-mere or 9-mere (or a
polypeptide of even 10 to 12 or more aminoacids). As a result, in
the regional lymph node this specific polypeptide can subsequently
be presented to memory cells within the restrictions of the Major
Histocompatibility Complex (MHC). Cytotoxic CD8+ T cells are then
generated, which have homing properties, staging the immune
response in the original area defined by receptors on endothelial
cells of small blood vessels causing the extravasations of these
cytotoxic T-cells.
[0137] In case of the desired sensitization of the immune system of
a melanoma patient following the treatment regimen of the
invention, comprising a low sensitizing dose of about 0.4% followed
by a challenge dose of about 0.04%, the T-cell mediated
cytotoxicity can be directed toward the diseased cells, such as
melanocytes. It may be particularly advantageous to repeat the
administration to provide a continuous exposure of challenge dose
of DPCP to the immune system and thereby boosting the immune
response.
[0138] In some instances, the repeated challenge doses of DPCP
results in a systemic immune reaction against all diseased cells
provides an excellent means to combat also distant metastases, even
micrometastases, that are not accessible to surgical methods or
radiotherapy and which are not accessible for topical drug
administration. The capability of melanomas to spread out and to
form local and distant metastases is a common problem in treatment
of patients suffering from malignant melanomas. This problem can be
effectively eliminated with the methods and medicaments of this
invention.
[0139] The immune response induced in the mammal by administering
to the mammal the low sensitizing dose of DPCP following by a
challenge dose of DPCP may include cellular immune responses
mediated by CD8+ T cells, capable of killing tumor and infected
cells, and CD4+ T cell responses. Humoral immune responses,
mediated primarily by B cells that produce antibodies following
activation by CD4+ T cells, may also be induced. A variety of
techniques may be used for analyzing the type of immune responses
induced by the compositions of the present invention, which are
well described in the art; e.g., Coligan et al., Current Protocols
in Immunology, John Wiley & Sons Inc., 1994.
[0140] For example, the anticancer activity of the treatment
regimen of the invention can be evaluated using standard in vitro
and in vivo assays. The ability of a composition to specifically
inhibit the growth of tumor cells can be assayed using tumor cell
lines in vitro, or in xenograft animal models in vivo. A preferred
protocol for such growth curve assays is the short term cell
viability assay described in Asai et al. (2003, cited above). In
established xenograft models of human tumors, the treatment regimen
of the invention is administered either directly to the tumor site
or systemically, and the growth of the tumor is followed by
physical measurement. A preferred example of a suitable in vivo
tumor xenograft assay is also described in Asai et al. (2003, cited
above). Other examples are described in Scorski et al., Proc. Natl.
Acad. Sci. USA, 94: 3966-3971 (1997) and Damm et al., EMBO J.,
20:6958-6968 (2001).
[0141] When "an immunologically effective amount," "an anti-tumor
effective amount," "a tumor-inhibiting effective amount," or
"therapeutic amount" is indicated, the precise amount of the
treatment regimen of the present invention to be administered can
be determined by a physician with consideration of individual
differences in age, weight, tumor size, extent of infection or
metastasis, and condition of the patient. It can generally be
stated that a pharmaceutical composition comprising the subject
cells of the invention, may be administered at a dosage to be
determined during appropriate clinical trials. The optimal dosage
and treatment regime for a particular patient can readily be
determined by one skilled in the art of medicine by monitoring the
patient for signs of disease and adjusting the treatment
accordingly.
[0142] Without wishing to be bound by any particular theory, it is
believed that the treatment regimen of the invention activates T
helper cells (also known as effector T cells or Th cells), which
are a sub-group of lymphocytes (a type of white blood cell or
leukocyte) that play an important role in establishing and
maximizing the capabilities of the immune system and in particular
in activating and directing other immune cells. Different types of
Th cells have been identified that originate in outcome of a
differentiation process and are associated with a specific
phenotype. Following T cell development, matured, naive (meaning
they have never been exposed to the antigen to which they can
respond) T cells leave the thymus and begin to spread throughout
the body. Naive T cells can differentiate into a T-helper 1 (Th1),
T-helper 2 (Th2), T-helper 17 (Th17) or regulatory T cell (Treg)
phenotype.
[0143] Each of these Th cell types secretes cytokines, proteins or
peptides that stimulate or interact with other leukocytes,
including Th cells. However, each cell type has a peculiar
phenotype and activity that interferes and often conflict with the
other.
[0144] Th1, Th2, and Th17 (inflammatory T-helper or inflammatory
Th), promote inflammation responses trough secretion of
pro-inflammatory cytokines, such as IL-1, IL-6, TNF-a, IL-17, IL21,
IL23, and/or through activation and/or inhibition of other T cell
including other Th cells (for example Th1 cell suppresses Th2 and
Th17, Th2 suppresses Th1 and Th17). Tregs instead, are a component
of the immune system that suppresses biological activities of other
cells associated to an immune response. In particular, Tregs can
secrete immunosuppressive cytokines TGF-beta and Interleukin 10,
and are known to be able to limit or suppress inflammation.
[0145] Th17 cells or otherwise cells exhibiting Th17 cell phenotype
may have a variety of specific phenotypic properties, depending on
the conditions employed. Such phenotypic properties include
production of IL-17A and IFN.gamma.. Moreover, cells activated by
the treatment regimen of the invention can produce both IL-17A and
IFN.gamma. and help reduce tumor cell growth. It is believed that
the cells activated by the treatment regimen of the invention
exhibits inflammatory characteristics with an antitumor
capacity.
[0146] The cytokines that regulate human Th17 cell differentiation
have largely been identified (Korn et al., 2009 Annu Rev Immunol
27: 485). IL-1.beta., IL-6, IL-21, IL-23 and TGF.beta. play key
roles in inducing, expanding and maintaining human Th17 cells
(Acosta-Rodriguez et al., 2007 Nat Immunol 8: 942; Wilson et al.,
2007 Nat Immunol 8: 950; Yang et al., 2008 Nature 454: 350). Given
that Th17 cells are involved in augmenting tumor immunity and in
exacerbating multiple autoimmune disorders (Chen et al., 2008
Immunol Res 41: 87; Muranski et al., 2008 Blood 112: 362), it is
believed that the treatment regimen of the invention provides a
therapeutic benefit to the patient by activating Th17 cells or
induce CD4 T helper precursor cells along the Th17 differentiation
pathway.
[0147] Any method can be used to determine whether or not the
progression rate of skin cancer is reduced. For example, the
progression rate of skin cancer can be assessed by imaging tissue
at different time points and determining the amount of cancer cells
present. The amounts of cancer cells determined within tissue at
different times can be compared to determine the progression rate.
After treatment as described herein, the progression rate can be
determined again over another time interval. In some cases, the
stage of skin cancer after treatment can be determined and compared
to the stage before treatment to determine whether or not the
progression rate was reduced.
Combination Therapy with an Immunological Agent
[0148] The treatment regimen of the invention can be used in
combination with one or more existing immunological agents. The
induction of an immune response may be enhanced, accelerated,
prolonged by the prior, simultaneous or subsequent use of immune
modifying compounds. The purpose of the therapies disclosed herein
is to elicit an immune response against certain desired antigens,
which elicitation may be enhanced by administering compounds
capable of activating or stimulating immune responses. Such
compounds may include various adjuvants and immune modifiers known
in the art. In one embodiment, the use of compounds or compositions
that are able to recruit lymphocytes to the site of the lesion, to
activate professional antigen presenting cells (such as dendritic
cells or langerhans cells), may be combined with the treatment
regimen of the invention. For instance Toll like receptor (TLR)
activating compounds and/or adjuvants such as LPS, lipid A,
peptidoglycans, flagellins, dsRNA, ssRNA, CpG DNA, Pam3Cys or
immunemodifyers such as imiquimod or resiquimod, CD40 ligands or
activating antibodies may be systemically, but preferably
topically, applied to stimulate a local inflammatory response in
the lesion treated according to the invention. Adjuvants may also
be advantageously used in combination with the invention.
Furthermore, compounds such as cytokines (interleukins), chemokines
and interferons that stimulate, enhance or prolong an immune
response can be used in combination with the treatment regimen of
the invention. This can be done by providing them directly or by
stimulating their local synthesis or release. Particularly the use
of interferon gamma and interleukins may be used to stimulate the
generation of a cellular and humoral immune response against the
desired antigen, in particular by recruitment and activation of
professional antigen presenting cells.
[0149] For use in treating a mammal with cancer such as skin
cancer, in accordance with the present invention, the cancer must
be one that responds to an immunological agent directed against a
target cancer-cell antigen. Examples of immunological agents, and
associated cancers which are targets for the agent, include agents
whose immunological moiety is designed for targeting CD19 and CD20,
for treating of B-lineage leukemias, such as chronic lymphoblastic
leukemia (CLL) and non-Hodgkin-lymphomas (NHL), agents targeting
CD22, for treating hairy cell leukemias, agents targeting CD25,
CD7, CD64, and CD33, for treating various haematological
malignancies expressing CD25, CD7, CD64, or CD33, respectively,
agents targeting MCSP, for treating malignant melanomas, agents
targeting a Lewis Y Antigen, for treating adenocarcinomas, and
agents targeting IL13 or EGFR, for treating a variety of tumors
known to express these antigens, such as glioblastomas.
[0150] Thus, an aspect of the invention involves identifying cancer
patients who are candidates for effective anti-cancer treatment
with an immunological agent, but for whom combined treatment with
the treatment regimen of the invention is desired to enhance the
anti-tumor efficacy of the immunological agent.
[0151] In the preferred treatment method, the subject is
administered the immunological agent in an amount that is effective
inhibiting proliferation of cancer cells in the subject. The dose
administered and the dosing schedule will follow, for example,
known or recommended doses for antibody agents currently in use for
anti-tumor therapy, such as Rituximab, as indicated, for example,
in the drug product insert or published clinical or animal-model
data. One advantage of the present invention is that
lower-than-normal doses of the immunological agent can be
administered, if necessary, due to the compensating enhancement
effect of the treatment regimen of the invention. Thus, a kit
containing a dose of the immunological agent could optionally
contain a product insert having one set of directions for using the
agent in monotherapy, and another set of directions for using DPCP
in a combination therapy to sensitize the subject. The set of
instructions for the combination therapy could recommend a lower
dose of the immunological agent, when used in combination with the
treatment regimen of the invention, and/or a different dosing
regimen for one or both agents, when used together, than would
normally be recommended for the immunological agent when used
alone.
[0152] The treatment regimen of the invention may be administered,
before, during, or after administration of the immunological agent.
Typically, the immunological agent and DPCP are administered in a
common dosing regimen, and the two compounds themselves may be
administered in a combined-drug composition. However, a dosing
regimen in which the sensitizing and challenge dose of DPCP of the
invention is administered before or after administering the
immunological agent is also contemplated. For example, a subject
under treatment with an immunological agent may be subsequently
placed on a combined therapy that includes the treatment regimen of
the invention.
[0153] Alternatively, the subject may be initially administered
with the treatment regimen of the invention comprising a low
sensitizing dose of DPCP and a challenge dose of DPCP followed by
the administration of the immunological agent at a later time. In
this type of treatment schedule, the low and high doses of DPCP
serves, in part, to sensitize the cancer cells towards responding
to the immunological agent.
[0154] The immunological agent may be administered by direct
injection of a tumor or its vasculature. Alternatively, the tumor
may be infused or perfused with the agents using any suitable
delivery vehicle. The agents may be administered locally to an
affected organ. Systemic administration may also be performed.
Continuous administration may be applied where appropriate; for
example, where a tumor is excised and the tumor bed is treated to
eliminate residual disease. Delivery via syringe or catheterization
is preferred. Such continuous perfusion may take place for a period
from about 1-6 hours, to about 6-12 hours, to about 12-24 hours, to
about 1-2 days, to about 1-2 weeks or longer following the
initiation of treatment. Generally, the dose of the therapeutic
composition via continuous perfusion will be equivalent to that
given by a single or multiple injections, adjusted over a period of
time during which the perfusion occurs.
[0155] The immunologic agent can be administered to a subject, such
as a human patient, in a formulation and in an amount effective to
achieve a clinically desirable result. For the treatment of cancer,
desirable results include reduction in tumor mass (as determined by
palpation or imaging; e.g., by radiography, radionucleotide scan,
CAT scan, or MRI), reduction in the rate of tumor growth, reduction
in the rate of metastasis formation (as determined e.g., by
histochemical analysis of biopsy specimens), reduction in
biochemical markers (including general markers such as ESR, and
tumor specific markers such as serum PSA), and improvement in
quality of life (as determined by clinical assessment, e.g.,
Karnofsky score), increased time to progression, disease-free
survival and overall survival.
[0156] In another embodiment, the treatment regimen of the present
invention can be combined with the use of Nitrogen mustard
(mechlorethamine) in the treatment of cancer. Nitrogen Mustard is a
chemotherapy drug that is normally given intravenously to treat the
entire body. When mixed in an ointment, it is a useful treatment
for lymphomas of the skin. In this regard, see for example, U.S.
Patent Application Publication No. 20100041767 for compositions and
methods of treating cancer comprising Nitrogen Mustard. The
extensive disclosure provided in US20100041767 is incorporated by
reference as if set forth in its entirety herein.
EXPERIMENTAL EXAMPLES
[0157] The invention is further described in detail by reference to
the following experimental examples. These examples are provided
for purposes of illustration only, and are not intended to be
limiting unless otherwise specified. Thus, the invention should in
no way be construed as being limited to the following examples, but
rather, should be construed to encompass any and all variations
which become evident as a result of the teaching provided
herein.
Example 1
Low Dose Sensitization of DPCP for the Treatment of Warts
[0158] Patients were initially sensitized with 0.4% DPCP gel at the
primary wart site. Approximately 14 days later and weekly
thereafter for various periods, a challenge dose is then applied. A
challenge dose of 0.04% DPCP was employed. The DPCP used was
incorporated in a unique blend of surfactants, a viscosity agent,
and a preservative. See Table 1 and 2.
TABLE-US-00001 TABLE 1 0.4% DPCP sensitizing dose % 1000 gram batch
Diphenylcyclopropenone 0.40 4.0 Butylated hydroxytoluene NF 0.02
0.2 Polysorbate 80 NF 49.79 497.9 Isopropyl myristate NF 49.79
497.9
TABLE-US-00002 TABLE 2 0.04% DPCP challenge dose % 1000 gram batch
Diphenylcyclopropenone 0.040 0.40 Butylated hydroxytoluene NF 0.01
0.10 Polysorbate 80 NF 49.975 499.75 Isopropyl myristate NF 49.975
499.75
[0159] It was observed that the treatment regimen of 0.4% DPCP
sensitizing dose in combination with a challenge dose of 0.04% DPCP
exhibited at least two benefits. First, the treatment regimen using
a low sensitizing dose of 0.04% DPCP avoided unnecessary adverse
events compared to a treatment regimen using a 2.0% DPCP
sensitizing dose. Without wishing to be bound by any particular
theory, it is believed that subjects using a 2.0% DPCP sensitizing
dose develop a severe reaction at the site of administration
including minor blistering and weeping. The present treatment
regimen avoids this severe reaction.
[0160] The second benefit of the treatment regimen is derived from
the challenge dose. Without wishing to be bound by any particular
theory, it is believed that potency of the challenge dose needs to
be inversely proportional to the sensitizing dose. The starting
challenge dose typically employed when started at 2.0% DPCP is
0.002% DPCP. It is believed that a 2.0% DPCP sensitizing dose is in
essence an "overdose" and the subject becomes hypersensitive to
DPCP and therefore requires the very low challenge dose of 0.002%
and in some cases even lower (e.g., 0.001%). In contrast to the
2.0% DPCP sensitization dose treatment regimen, the current
treatment regimen employing a challenge dose of 0.04% DPCP did not
result in observable severe reactions at the application site. In
this regard, the current treatment regimen provides a benefit to
other regiments because the 0.04% DPCP challenge dose has been
tolerated so well in the subjects tested. Accordingly, another
study was conducted which applied the 0.4% DPCP sensitizing dose on
Day 0 and starting on Day 14 application of the 0.04% DPCP
challenge dose twice weekly for seven more weeks. The present study
has demonstrated an excellent wart clearance rate with just 6
weekly challenge doses. Without wishing to be bound by any
particular theory, it is believed that 7 weeks of biweekly
treatment will produce excellent wart clearance rates.
[0161] Experiments were designed to determine the efficacy and
safety of administering DPCP at a low dose 0.4% sensitizing and a
0.04% therapy dose for the treatment of warts.
[0162] The materials and methods employed in the experiments
disclosed herein are now described.
Study Design and Outcomes
[0163] Institutional review board approval was obtained for this
study, which was performed using Good Clinical Practice Guidelines
and was compliant with the Code of Federal Regulation of the US
Food and Drug Administration. A single center, randomized,
double-blind, placebo control study using low dose DPCP in a
non-volatile vehicle for the treatment of non-genital warts was
conducted. Patients were assigned to a treatment or placebo group
in a 2:1 fashion. The two study gels were identical in appearance.
The treatment group was sensitized with 0.1 ml of 0.4% DPCP gel
which was applied to the inner arm and washed off in 24 hours.
Fourteen days after the sensitization dose, 0.1 ml of 0.04% DPCP
gel was applied to each wart, up to a total of 4 warts, for 7
consecutive weeks (Day 14, 21, 28, 35, 42, 49, 56). A final
follow-up examination was performed on day 70. Patients were
assessed at baseline and during each of 7 week treatment visits and
on day 70 follow up.
[0164] Efficacy was based on Lesion Surface Area. The size of each
qualifying verruca wart was determined at each visit by measuring
the longest dimension (long axis) and the corresponding widest
dimension (90 to the long axis).
[0165] Investigator's Global Assessment Score (IGAS) was calculated
based upon the following 4 point scale: 3 points=Complete
clearance; 2 points=partial clearance: >50% reduction in the
area of all treated wart; 1 point=partial eradication: <50%
reduction in the area of all treated warts; 0 points=treatment
failure: complete or partial eradication not achieved.
[0166] Immunotherapeutic responses were characterized by grading
the erythema, edema, induration, and scaling on a four-point scale:
0 (none) to 4 severe at each visit.
[0167] Efficacy endpoints were determined based on the percent of
patients achieving complete and partial eradication as measured by
IGAS and reductions in warts lesion surface area. Subjects were
assessed for the extent of their immunotherapeutic response to
treatment based upon the degree of erythema, edema, induration and
scaling. Safety was evaluated at each visit by recording and
grading adverse events and ease of ambulation 4 point grading
system was used.
Study Population
[0168] Adults 18-75 years of age in general good health with at
least one non-genital cutaneous wart 5-20 mm in size were eligible
for participation in the study. Women of child bearing potential
(WOCBP) had a negative pregnancy test at baseline visit and were to
use highly effective contraception throughout the study. Pregnant
or nursing women were excluded. Patients with unstable medical
condition or history of immunosuppression were excluded. Use of
systemic steroids, immunosuppressants, immunomodulators or
cimetidine was not allowed for 4 weeks prior to enrollment. Any
prior wart therapy was not allowed for 4 weeks. Patients could not
have significant scarring or active dermatologic condition in the
treatment area. Patients could not be actively enrolled in another
clinical trial within the previous 30 days.
[0169] The results of the experiments disclosed herein are now
described.
[0170] A total of 18 subjects with non-genital warts were enrolled
and randomized in the study (11 female and 7 males). A total of 17
subjects completed day 14 for sensitization results and 14 patients
completed the study. Four subjects withdrew during the study for
personal reasons.
[0171] A total of 8 subjects (25 total warts) in the DPCP group and
6 subjects (15 warts) in the vehicle group completed the study. The
age range was 19-79 years old.
[0172] Sensitization reactions developed in 9 of 12 (75%) of
subjects who received 0.4% DPCP gel and 0 of 6 (0%) subjects who
received vehicle developed a sensitization reaction, Chi-square
9.0, p=0.0027.
[0173] All subjects (100%) in the DPCP group obtained a clinical
response/improvement. Partial to complete clearance occurred in
19/25 (76%) warts and of the 6 warts that did not respond, 4 of 6
(67%) were in subjects who did not elicit a sensitization
reaction.
[0174] Complete clearance occurred in 11 of 25 warts (44%) in the
DPCP group and 1 of 15 (6.7%) of vehicle treated warts, Chi-square
6.22, p=0.01
[0175] One subject with numerous mosaic warts on the plantar foot
in the DPCP group had 4 warts treated and achieved complete
clearance of those 4 warts and all surrounding untreated warts
(>50).
[0176] No significant side effects were reported other than skin
rash at the sensitization site. Patients reported both treatments
to be highly tolerable.
[0177] The results presented herein demonstrate that using a lower
dose of a sensitizer such as 0.4% DPCP gel as compared to prior art
sensitizing dose of about 2.0% DPCP is safer since the low dose
sensitizer of about 0.4% DPCP decreases potential adverse reaction.
The sensitizing dose of about 0.4% DPCP in combination with a
challenge dose of about 0.04% DPCP is effective at eliciting an
immune reaction and is more effective than the control group at
successfully clearing warts.
Example 2
Low Dose Sensitization of DPCP for the Treatment of Verruca
Conditions
[0178] Institutional review board approval was obtained for this
study, which was performed using Good Clinical Practice Guidelines
and was compliant with the Code of Federal Regulation of the US
Food and Drug Administration. A single center, 24 subject,
randomized, double-blind, placebo control study using low dose DPCP
in a non-volatile vehicle for the treatment of non-genital warts of
established.
[0179] Patients are assigned to a treatment or placebo group in a
2:1 fashion. The two study gels are identical in appearance. Both
groups are sensitized with 0.1 ml of 0.4% DPCP gel which is applied
to the inner arm and washed off in 24 hours. Fourteen days after
the sensitization dose, 0.1 ml of 0.04% DPCP gel or placebo is
applied to each wart, up to a total of 4 warts, twice a week for 7
consecutive weeks (Day 14, 21, 28, 35, 42, 49, 56, 63). A final
follow-up examination is performed on day 77. Patients are assessed
at baseline and during office visits on days 14, 28, and 63 and on
the day 77 follow up visit.
[0180] Efficacy is based on Lesion Surface Area. The size of each
qualifying verruca wart is determined at each visit by measuring
the longest dimension (long axis) and the corresponding widest
dimension (90 to the long axis).
[0181] Investigator's Global Assessment Score (IGAS) is calculated
based upon the following 4 point scale: 3 points=Complete
clearance; 2 points=partial clearance: >50% reduction in the
area of all treated wart; 1 point=partial eradication: <50%
reduction in the area of all treated warts; 0 points=treatment
failure: complete or partial eradication not achieved.
[0182] Immunotherapeutic responses are characterized by grading the
erythema, edema, induration, and scaling on a four-point scale: 0
(none) to 4 severe at each visit.
[0183] Efficacy endpoints are determined based on the percent of
patients achieving complete and partial eradication as measured by
IGAS and reductions in warts lesion surface area. Subjects are
assessed for the extent of their immunotherapeutic response to
treatment based upon the degree of erythema, edema, induration and
scaling. Safety is evaluated at each visit by recording and grading
adverse events and ease of ambulation 4 point grading system is
used.
[0184] The materials and methods employed in the experiments
disclosed herein are now described.
Study Design
[0185] Day 0--First Office Visit
[0186] All subjects (both treated and placebo groups) are
sensitized with the initial sensitizing dose of 0.4% DPCP gel
applied directly to one target wart and to the inner aspect of the
right arm and then covered with an occlusive adhesive bandage pad
for 24 hours.
[0187] Day 14--Second Office Visit
[0188] The Investigator can determine if sensitization occurred at
either of the application sites. If on day 14, the first "treatment
visit", no visible evidence of skin sensitization is observed then
the subject can be dropped from the study. If on day 14 the
investigator determines that sensitization has occurred, than the
first treatment dose using the challenge dose (0.04% DPCP gel or
placebo) randomly assigned upon enrollment can be administered by
the investigator to all target warts and then covered with an
occlusive adhesive bandage pad for 24 hours.
[0189] The patient is provided with a tube containing the
appropriate challenge product (0.04% DPCP gel or placebo) with
detailed instructions on how to apply the product two times per
week and the proper handling and storage of the product between
applications.
[0190] Treatment Weeks 1, 2, and 3--Days 18, 21, 25
[0191] Two times per week the patient can apply the treatment dose
(0.04% DPCP gel or placebo) to all target warts and then cover with
an occlusive adhesive bandage pad for 24 hours. The patient is
instructed to omit an application to any target wart(s) that
exhibit an excess of inflammation and to resume applications when
the inflammation has subsided.
[0192] Treatment Day 28--Office Visit 3
[0193] Efficacy for each target lesion is graded and any adverse
reactions can be reviewed, recorded, and treated as deemed
medically necessary. Photographs of warts taken are compared with
initial photographs from the sensitization visit.
[0194] The Investigator can apply the treatment dose (0.04% DPCP
gel or placebo) to all target warts and then cover with an
occlusive adhesive bandage pad for 24 hours. The Investigator can
omit an application to any target wart(s) that exhibit an excess of
inflammation and the patient is instructed to resume applications
when the inflammation has subsided.
[0195] Treatment Weeks 3, 4, 5, and 6--Days 31, 35, and 38 45, 49,
52, 56, 59
[0196] Two times per week the patient can apply the treatment dose
(0.04% DPCP gel or placebo) to all target warts and then cover with
an occlusive adhesive bandage pad for 24 hours. The patient is
instructed to omit an application to any target wart(s) that
exhibit an excess of inflammation and to resume applications when
the inflammation has subsided.
[0197] Treatment Day 63--Office Visit 4
[0198] Efficacy for each target lesion is graded and any adverse
reactions can be reviewed, recorded, and treated as deemed
medically necessary. Photographs of warts taken are compared with
initial photographs from the sensitization visit.
[0199] The Investigator can apply the treatment dose (0.04% DPCP
gel or placebo) to all target warts and then cover with an
occlusive adhesive bandage pad for 24 hours. The Investigator can
omit an application to any target warts) that exhibit an excess of
inflammation. This is the final treatment. The patient is
instructed to stop at home treatments and should return any unused
gel.
[0200] Day 77--Office Visit 5--Follow Up Visit
[0201] Efficacy for each target lesion is graded and any adverse
reactions can be reviewed, recorded, and treated as deemed
medically necessary. Photographs of warts taken are compared with
initial photographs from the sensitization visit.
Study Population
[0202] Adults 18-75 years of age in general good health with at
least one non-genital cutaneous wart 5-20 mm in size are eligible
for participation in the study. HIV+ patients with CD4+ cell counts
greater than 300 are also eligible. Women of child bearing
potential (WOCBP) had a negative pregnancy test at baseline visit
and are to use highly effective contraception throughout the study.
Pregnant or nursing women are excluded. Patients with unstable
medical condition are excluded. Use of systemic steroids,
immunosuppressants, immunomodulators or cimitidine is not allowed
for 4 weeks prior to enrollment. Any prior wart therapy is not
allowed for 4 weeks. Patients could not have significant scarring
or active dermatologic condition in the treatment area. Patients
could not be actively enrolled in another clinical trial within the
previous 30 days.
[0203] The results of the experiments disclosed herein are now
described.
[0204] To date a total of 7 subjects have been enrolled and
randomized in the study. A total of 5 subjects (6 total warts) in
the DPCP group and 2 subjects (3 warts) in the vehicle group have
completed the study.
[0205] In this study both the treatment group and the placebo group
received a 0.4% DPCP sensitization dose and all were successfully
sensitized.
[0206] 4/5 subjects (80%) in the DPCP group obtained a clinical
response/improvement. Complete clearance occurred in 4/6 (67%) of
the treated warts and 1/6 (16%) achieved greater than 50% clearance
and 1/6 (16%) exhibited no clearance. No partial or complete
clearance occurred in the 3 warts treated in the placebo group. See
Table 3.
TABLE-US-00003 TABLE 3 Subject # Wart Location Treatment Clearance
Score 107 0.5 mm rt hand DPC 7 weeks +3 108 0.5 mm left arm DPC 5
weeks +3 109 0.5 mm left finger Placebo 5 weeks 0 109 0.2 mm
Placebo 5 weeks 0 110 0.9 mm left hand DPC 7 weeks +3 110 0.5 mm
DPC 7 weeks +2 111 0.5 mm left hand Placebo No show for treatment
112 0.5 mm left finger DPC 7 weeks 0 113 0.6 mm rt. finger Placebo
Patient withdrew after 5 weeks 114 0.4 mm rt. finger DPC 7 weeks
+3
[0207] No significant side effects were reported other than skin
rash at the sensitization site. Patients reported both treatments
to be highly tolerable.
[0208] The results presented herein demonstrate that using a lower
dose of a sensitizer such as 0.4% DPCP gel as compared to prior art
sensitizing dose of about 2.0% DPCP is safer since the low dose
sensitizer of about 0.4% DPCP decreases potential adverse reaction.
The sensitizing dose of about 0.4% DPCP in combination with a
challenge dose of about 0.04% DPCP applied topically twice a week
for seven weeks is effective at eliciting an immune reaction and is
more effective than the control group at successfully clearing
warts, Chi-square 7, p=0.01. The results presented herein
demonstrate that using a lower dose of a sensitizer such as 0.4%
DPCP gel compared to the standard sensitizing dose of 2.0% is safer
since the lower dose sensitizer of the invention decreases
potential adverse reaction.
[0209] Without wishing to be bound by any particular theory, it is
believed that the challenge dose can be applied every other day or
even more frequently.
Example 3
Low Dose Sensitization of DPCP for the Treatment of Cutaneous
Metastatic Melanoma
[0210] Patients are initially sensitized with 0.4% DPCP gel by way
of topical administration at the target site. Approximately 14 days
later and weekly thereafter for various periods, a challenge dose
is then applied. A challenge dose of 0.04% DPCP is employed. The
DPCP used was incorporated in a unique blend of surfactants, a
viscosity agent, and a preservative. See Table 1 and 2.
[0211] Without wishing to be bound by any particular theory, the
treatment regimen using a low sensitized dose of 0.4% DPCP allows
for a greater range of challenge doses and frequency of about 0.04%
DPCP. This treatment regimen can be an effective treatment of many
types of skin cancer, including but not limited to basal cell
carcinoma, actinic keratosis, Bowen's disease, squamous cell
carcinoma, cutaneous melanoma and the like.
[0212] A patient exhibiting symptoms of skin cancer or precancerous
skin conditions would receive an initial low sensitizing dose of
0.4% DPCP with challenge doses starting at 0.04%. In some
instances, the challenge dose can be increased to a desirable
amount such as up to 0.2% DPCP. The frequency of application of the
challenge dose can start at twice a week. In some instances, the
frequency of the challenge does can be increased to three or four
times a week.
[0213] Depending on the type of skin cancer (for example squamous
cell carcinoma and cutaneous melanoma), it may be desirable to
start with a sensitizing dose of 0.4% DPCP with challenge doses
starting at 0.04% but possibly increasing up to 0.5% and even up to
2.0%. The ability to increase the challenge dose is based on the
discovery that the low sensitization dose allows for having the
challenge dose be higher than otherwise possible if the sensitizing
dose was higher than 0.4% DPCP. The low sensitizing dose allows for
a higher challenge dose having less adverse reactions compared to
the adverse reactions using a sensitizing that is higher than 0.4%
DPCP. The frequency of the challenge does can start at twice a week
and if needed be increased to daily use.
Example 4
Employing the Topical Immunomodulator Diphenylcyclopropenone in a
Stabilized Gel to Treat in-Transit Metastases in Cutaneous
Melanoma
[0214] The following experiments were designed to conduct a Phase
II open-label study to determine the dose response and safety and
efficacy of DPCP incorporated in a unique blend (see Table 1 and 2)
as a topical immunotherapy for the treatment of cutaneuos melanoma.
It is believed that the DPCP incorporated in a unique blend
provides a new topical immune based therapy which provides an
effective, low cost, safe, easy to use, noninvasive therapy for the
treatment of in-transit metastases in cutaneous melanoma.
[0215] The primary purpose of this study is to test the safety of
multiple applications of the treatment formulation. The study also
anticipates an indication of the effectives of the DPCP formulation
to treat cutaneous melanoma in-transit metastases.
[0216] The materials and methods employed in the experiments
disclosed herein are now described,
Phase IIa Clinical Study
[0217] The present study is an open-label study to determine the
response and characteristics, safety and efficacy, of the DPCP gel
composition as a topical immunotherapeutic agent for the treatment
of in-transit metastases in cutaneous melanoma. The products
evaluated include 0.4% DPCP, in a non-volatile gel vehicle as the
initial treatment topically applied in a single dose and 0.04% DPCP
in the same gel vehicle applied to the target lesions biweekly for
14 weeks. The estimated duration of the study is 142 days with 112
days of treatment followed by subject examination on day 142.
[0218] The study population includes male or female subjects, aged
18 years or older with in-transit cutaneous melanoma metastases.
Inclusion criteria are as follows: [0219] Male or non-pregnant
female subjects aged 18-75 years of age. [0220] Written and verbal
informed consent must be obtained. [0221] Subjects with clinically
diagnosed cutaneous melanoma with multiple in-transit metastases.
Investigator must determine that the subject's metastatic lesions
are not candidates for excision or other approved treatments.
[0222] Women of childbearing potential (WOCBP) must be willing to
practice effective contraception for the duration of the study.
[0223] WOCBP must have a negative urine pregnancy test at the
baseline visit. [0224] Subjects must be willing and able to have
the therapy applied by the investigator, must be willing and able
to apply the therapy to themselves and must be willing and able to
comply with study instructions and return to the clinic for
required visits.
[0225] Exclusion criteria include the following: [0226] Subjects
taking any of the following systemic or topical therapies within 4
weeks of enrollment: cimetidine, corticosteroids, or
immunosuppressants, and/or any other medicines that may affect the
outcome of this study. [0227] Subjects who have active localized or
systemic medical conditions that in the opinion of the
investigator, would preclude their participation in the study.
[0228] Subjects with any underlying disease(s) or dermatological
condition of the affected area(s) that requires the use of
interfering topical or systemic therapy. [0229] Subjects who are
pregnant, nursing mothers, subjects planning a pregnancy during the
course of the study. [0230] Subjects who are unable to communicate
or cooperate with the Investigator due to language problems, poor
mental development, or impaired cerebral function [0231] Subjects
with any condition, which, in the Investigator's opinion, would
make it unsafe for the subject to participate in a research study.
[0232] Subjects who have been treated with another investigation
device or drug within 30 days prior to study enrollment.
Justification of Biopsies
[0233] The study includes a histological standard skin biopsy at
Day 0, Day 35, and the final treatment visit, Day 112. These
biopsies help to confirm the presence of viable melanoma at the
target site before, during, and at the end of the treatment period.
Additional tests can be performed on the biopsy tissue to determine
the level of immune system activity at the target site. CD8,
Natural Killer cells, TH17 cells, and cytokine levels are measured
to determine the level of immune system activity.
Justification of the Sample Size
[0234] DPCP has an extensive history of previous human use but it
has never been subjected to the full clinical development process
required for regulatory approval in the United States. Up to this
point DPCP formulations have been prepared as required in small
lab-scale batches using acetone as the vehicle. This study employs
a vehicle that avoids both the handling and skin damaging drawbacks
of employing acetone as the vehicle. The study also uses a much
lower sensitization concentration of 0.4% DPCP versus the usually
employed 2.0% sensitization concentration.
Study Procedures
[0235] Day 0--First Office Visit:
[0236] Sensitization visit: Following signed written Informed
Consent and confirmation of eligibility, all subjects undergo a
medical history including review of concomitant medications, and a
dermatologic exam is performed to confirm the presence of eligible
in-transit cutaneous melanoma metastases. A pregnancy test is
administered in WOCBP and must be negative in order for the subject
to participate in the trial. A standard skin punch biopsy can be
performed to confirm viable melanoma at the target site.
Photographs of the target lesions can be taken and the initial
sensitizing dose can be applied directly to one target lesion and
to the inner aspect of the right arm. The sensitizing sites can
then be covered with an occlusive adhesive bandage pad for 24
hours.
[0237] Day 14--Second Office Visit
[0238] The Investigator can determine if sensitization occurred at
either of the application sites. If on day 14, the first "treatment
visit", no visible evidence of skin sensitization is observed then
an additional sensitization dose of 0.4% DPCP can be applied to the
target lesions and covered for 24 hours. The patient is instructed
to return in one week.
[0239] At the discretion of the treating physician, a 0.4% DPCP
dose can be administered at any office visit if the melanoma
medications are insufficiently inflamed or not responding to the
lower 0.04% DPCP take home product.
[0240] If on day 14, the investigator determines that sensitization
has occurred, than the first treatment dose using the challenge
dose of 0.04% DPCP gel can be administered by the investigator to
all target lesions. The lesions are then covered with an occlusive
adhesive bandage pad for 24 hours. The patient can be provided with
a tube containing the challenge dose 0.04% DPCP gel with detailed
instructions on how to apply the product two times per week and the
proper handling and storage of the product between
applications.
[0241] Days: 17, 21, 24, 28, 31--Treatment Doses # 3 Thru 7
[0242] The challenge dose of 0.04% DPCP can be administered by the
subject to all target lesions and then covered with an occlusive
adhesive bandage pad for 24 hours. In the event one or more target
lesion(s) has a delayed type hypersensitivity (DTH) reaction of 4+
(e.g., large vesicles, bullae, and severe local reaction besides
erythema), the investigator/subject may elect to not perform a
scheduled treatment on the target lesion(s). The treatment schedule
is resumed when the inflammation subsides. During this period any
adverse reactions should be immediately reported to the Principal
Investigator by the subject.
[0243] Patient Visit 3--Treatment # 8--Day 35
[0244] Prior to the treatment regimen, a photograph of the target
lesions can be taken in order to grade the lesions. A standard skin
punch biopsy can be used to confirm viable melanoma at the target
site. Additional tests can be performed on the biopsy tissue to
determine the level of an immune response at the target site. CD8 T
cells, Natural Killer cells, TH17 cells, and cytokine levels can be
measured using standard assays to evaluate the level of immune
response at the target side.
[0245] The challenge dose of 0.04% DPCP can then be administered by
the Investigator to all target lesions and covered with an
occlusive adhesive bandage pad for 24 hours. In the event one or
more target lesion(s) has a DTH reaction of 4+ (e.g., large
vesicles, bullae, and severe local reaction besides erythema), the
investigator/subject may elect to not perform a scheduled treatment
on the target lesion(s). The treatment schedule is resumed when the
inflammation subsides. Any adverse reactions should be recorded
during this visit.
[0246] Days: 38, 42, 45, 59, 63, 66, 70, 73, 77, 80--Treatment
Doses #s 9 Thru 20
[0247] The challenge dose of 0.04% DPCP can be administered by the
subject to all target lesions. The lesions are then covered with an
occlusive adhesive bandage pad for 24 hours. In the event one or
more target lesion(s) has a DTH reaction of 4+ (e.g., large
vesicles, bullae, and severe local reaction besides erythema), the
investigator/subject may elect to not perform a scheduled treatment
on the target lesion(s). The treatment schedule is resumed when the
inflammation subsides. During this period any adverse reactions
should be immediately reported to the Principal Investigator by the
subject.
[0248] Patient Visit 4--Treatment # 21--Day 80
[0249] Prior to the treatment regimen, a photograph of the target
lesions can be taken in order to grade the lesions. The challenge
dose of 0.04% DPCP can then be administered by the Investigator to
all target lesions and covered with an occlusive adhesive bandage
pad for 24 hours. In the event that one or more target lesion(s)
has a DTH reaction of 4+ (e.g., large vesicles, bullae, and severe
local reaction besides erythema), the investigator/subject may
elect to not perform a scheduled treatment on the target lesion(s).
The treatment schedule is resumed when the inflammation subsides.
Any adverse reactions should be recorded during this visit.
[0250] Days: 84, 87, 91, 94, 98, 101, 105, 108--Treatment Doses #s
22 Thru 29
[0251] The challenge dose of 0.04% DPCP can be administered by the
subject to all target lesions. The lesions are then covered with an
occlusive adhesive bandage pad for 24 hours. In the event that one
or more target lesion(s) has a DTH reaction of 4+ (e.g, large
vesicles, bullae, and severe local reaction besides erythema), the
investigator/subject may elect to not perform a scheduled treatment
on the target lesion(s). The treatment schedule is resumed when the
inflammation subsides. During this period any adverse reactions
should be immediately reported to the Principal Investigator by the
subject.
[0252] Patient Visit 5--Treatment # 30--Day 112
[0253] Prior to treatment with a challenge dose of DPCP, a
photography of the target lesions can be taken for purposes of
grading the lesions. A standard skin punch biopsy can be performed
to confirm viable melanoma at the target site. Additional tests can
be performed on the biopsy tissue to determine the level of immune
system activity at the target site. CD8 T cells, Natural Killer
cells, TH17 cells, and cytokine levels can be measured using
standard assays in the art.
[0254] The challenge dose of 0.04% DPCP can then be administered by
the Investigator to all target lesions and covered with an
occlusive adhesive bandage pad for 24 hours. In the event one or
more target lesion(s) has a DTH reaction of 4+ (e.g., large
vesicles, bullae, and severe local reaction besides erythema), the
investigator/subject may elect to not perform a scheduled treatment
on the target lesion(s). The treatment schedule is resumed when the
inflammation subsides. Any adverse reactions should be recorded
during this visit.
[0255] Patient Visit 6--Follow Up Visit--Day 142
[0256] Final photographs of the target lesions are taken and the
target lesions are graded. The resolution or occurrence of any
adverse reactions should be recorded during this visit.
[0257] Without wishing to be bound by any particular theory, it is
believed that the risks of the present study are minimal. The most
common adverse effects of DPCP are a mild contact dermatitis/eczema
similar to poison ivy reaction, along with lymph node swelling.
Less common adverse effects are localized blistering,
hyperpigmentation, and eczema at a distant site from the
application site. Rare adverse effects are fever and chills,
fainting spells, flu-like symptoms, headache, palpitation, and
rarely contact leukoderma, erythema multiforme and urticaria. DPCP
has demonstrated that it is not mutagenic, teratogenic and has no
organ toxicity.
[0258] Potential risks of the medication is minimized by the study
through the use of a much lower sensitization concentration of 0.4%
DPCP versus the usually employed 2.0% sensitization concentration
along with the use the gelled DPCP composition of the present
invention that avoids the handling and skin damaging drawbacks of
the standard DPCP in acetone. Potential risk is also minimized by
utilizing trained physicians to closely monitor for any adverse
reaction, to withdrawal the subject if medically indicated and to
refer for treatment as deemed medically necessary. If a severe
blister reaction occurs which is a possible but uncommon reaction
of DPCP, cold wet compresses or even hydrocortisone cream or pill,
can be used.
Study Measurements
[0259] Efficacy of the treatment regimen can be assessed by the
following: [0260] Lesion Surface Area: the size of each qualifying
melanoma lesion is determined at each evaluation by measuring the
longest dimension (long axis) and the corresponding widest
dimension (90 to the long axis). [0261] Investigator's Global
Assessment Score (IGAS) is evaluated for all treated lesions as a
group based upon the following 4 point scale: 3 points--complete
eradication (e.g., elimination of all treated lesions and
restoration of normal epidermal lines and marking; 2
points--(partial eradication: >50% reduction in the area of all
treated lesions); 1 point--(partial eradication: <50% reduction
in the area of all treated lesions); 0 points--(treatment failure:
complete or partial eradication not achieved). Immunotherapeutic
responses are characterized by grading the erythema, edema,
induration, and scaling on a four-point scale, 0 (none) to 4 severe
at each visit.
Study Endpoints
[0262] Efficacy Endpoints can be determined based on the percent of
patients achieving complete and partial eradication, reductions in
Lesion Surface Area as well as the IGAS, over the treatment period
and on the follow up visit on day 142. Histological presence of
melanoma at the biopsy sites at the beginning and the end of the
treatment period can be confirmed. During the post-treatment period
efficacy measurements, test subject acceptance, and reported
adverse reactions can be evaluated.
[0263] Subjects are assessed for the extent of their
immunotherapeutic response to treatment based upon the degree of
erythema, edema, induration and scaling. CD8 T cells, Natural
Killer cells, TH17 cells, and cytokine level measurements are
evaluated to determine immune response to the treatment.
[0264] The disclosures of each and every patent, patent
application, and publication cited herein are hereby incorporated
herein by reference in their entirety. While this invention has
been disclosed with reference to specific embodiments, it is
apparent that other embodiments and variations of this invention
may be devised by others skilled in the art without departing from
the true spirit and scope of the invention. The appended claims are
intended to be construed to include all such embodiments and
equivalent variations.
* * * * *