Patient case: 64-year-old male with head and neck squamous cell carcinoma; genetic feature: CDKN2A

Clinical trial: Biological Vaccine: Semi-allogeneic Human Fibroblasts (MRC-5) Transfected With DNA

Summary: Hypothesis The incidence of toxicity in patients receiving the tumor DNA-transfected fibroblast vaccine will be acceptably low and the immunologic response rate sufficiently high to warrant further study of this therapy
  The study of the vaccine will proceed in two stages after the method of Simon (102). In the first stage, 15 patients will be accrued and treated. If two or fewer objective immunologic responses occur, the study will be terminated. If 3 or more responses are observed, the study will proceed to the second stage, accruing an additional 22 patients. If the second stage is complete and a total of 9 or more immunologic responses are observed among the 37 patients treated, the treatment response rate for the vaccine will be considered high enough to warrant further study. Conversely, if the evaluation of the vaccine concludes at the first stage, or if 8 or fewer total immunologic responses occur after completing the second stage, the vaccine will not be considered for further study.

Detailed description: This is a single institution open-label phase Ib clinical trial designed to determine the safety of immunization of patients with resected Head and Neck Squamous Cell Carcinoma (HNSCC) with lethally irradiated semi-allogeneic human fibroblasts (MRC-5) transfected with DNA derived from the subject's own tumor and to measure the immune response to the autologous tumor vaccine.
  Briefly, the plan is to use a two-stage trial design and to initially enroll 15 patients with Head and Neck Squamous Cell Carcinoma (HNSCC). The patients will undergo surgical resection to provide complete removal of the primary lesion with negative gross and microscopic margins. A portion of the primary tumor specimen not necessary for the pathologic diagnosis will be obtained to serve as a source of DNA for preparing the vaccine. Each DNA-based vaccine will contain 1 x 10e7 DNA-transfected human allogeneic fibroblasts. The vaccine will be lethally irradiated before it is used for immunization. It will be administered intradermally in the Outpatient Clinic for a total of four vaccinations delivered at weekly intervals.
  Patients delayed-type hypersensitivity (DTH) responses will be tested but will not be an eligibility criterion. Immunologic response to the vaccine will be evaluated. If there is no evidence of toxicity, and >3 of the 15 initial patients show immunologic response, the second stage of the study will be opened for accrual of 22 patients.
  To determine patient's response to the DNA-based vaccines, the frequency of T cells reactive with recipient cells transfected with the autologous tumor DNA will be measured by ELISPOT for IFN-y and compared with the response to non-transfected fibroblasts prior to and after vaccination. All patients will be monitored for Immunologic response by assays include ELISPOT, flow cytometry for lymphocyte markers, Annexin V binding, TcR expression, caspase3 activity and serum antibodies.

Eligibility: Inclusion Criteria:
  -  Pathological stage I-IVa HNSCC
  -  The subject must have a complete removal of the primary HNSCC lesion with negative gross and microscopic margins. Documentation of margins by frozen sections at surgery is recommended. Patients who have already had surgery and have available banked tumor samples can be enrolled AFTER surgery.
  -  At least 18 years of age.
  -  Karnofsky performance status >/= 70
  -  Adequate hematologic function:
  -  Absolute neutrophil count > 1,000/mm3
  -  Absolute lymphocyte count > 1,000/mm3
  -  Hemoglobin > 9 g/dL
  -  Platelets > 100,000/mm3
  -  Liver function tests:
  -  Bilirubin (total) < /=1.7 mg/dL
  -  Alkaline phosphatase < 252 u/L
  -  SGOT < 108 u/L
  -  Kidney profile:
  -  Serum electrolytes
  -  Sodium 136-146 mEq/L
  -  Potassium 3.5-5.0 mEq/L
  -  Bicarbonate 21-31 mEq/L
  -  Chloride 98-107 mmol/L
  -  Serum creatinine < 3 x ULN
  -  BUN 8-26 mg/dL
  -  At least a 12 week interval should have elapsed between prior surgery, radiation therapy, chemotherapy or any other treatment and the first vaccination. Patients should have recovered from surgery and adjuvant treatment.
  -  The effects of the tumor DNA-transfected fibroblast vaccine on the developing human fetus are unknown. For this reason women of child-bearing potential must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation and for 4 months after the last dose of the study vaccine, even if oral contraceptives are used. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately. Men treated or enrolled on this protocol must also agree to use adequate contraception prior to the study, for the duration of study participation, and 4 months after completion of the tumor DNA-transfected fibroblast vaccine administration.
  Exclusion Criteria:
  Patients will be EXCLUDED from participation in the study if any of the following apply:
  -  One or more of the Inclusion Criteria are not met.
  -  A significant history or current evidence of cardiac disease including, but not limited to: congestive heart failure, coronary artery disease, angina pectoris, uncontrolled hypertension, serious arrhythmias or myocardial infarction within the previous six months.
  -  Evidence of ongoing or active infection requiring antibiotic therapy.
  -  Active intracranial metastases. Patients with previously resected intracranial disease and/or previously irradiated intracranial metastases that have been clinically stable for four weeks are eligible.
  -  Pregnant or lactating women. Pregnant women are excluded from this study. Women of childbearing potential must have a negative pregnancy test per standard of care prior to the surgery for tumor removal. A second pregnancy test must be performed 7 days prior to the first vaccination and must be negative. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother, breastfeeding should be discontinued if the mother is treated on study.
  -  Patients requiring systemic corticosteroids (unless patients have had no corticosteroids within 4 weeks prior to start of study).
  -  Autoimmune disease including, but not limited to, rheumatoid arthritis, systemic lupus erythematous, multiple sclerosis, or ankylosing spondylitis.
  -  Patients who have post-obstructive pneumonia or other serious infection at the time of registration or other serious underlying medical condition that would impair the ability of the patient to receive protocol treatment.
  -  No prior malignancy is allowed except for adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer, or other cancer from which the patient has been disease-free for at least 5 years prior to registration.
  -  Uncontrolled intercurrent illness including, but not limited to psychiatric illness/social situations that would limit compliance with study requirements.
  -  HIV-positive patients receiving combination anti-retroviral therapy are excluded from the study. HIV testing will be performed in patients receiving combination anti-retroviral therapy when indicated per medical records review.
  -  Patients with clinical symptoms of Hepatitis B and/or Hepatitis C will be tested, if clinically indicated per medical records review. Positive results will be an exclusion criteria

Relevance to patient case: not relevant