Targeted Chemotherapy Using Focused Ultrasound for Liver Tumours

Study Overview
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Brief Summary
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This proof of concept study proposes targeted delivery of a broad-spectrum cytotoxic agent (doxorubicin), via a specially formulated LTSL (ThermoDox®) activated by mild hyperthermia, by using focused ultrasound (FUS), to achieve enhanced intra-tumoural doxorubicin concentrations for the same systemic dose. Adult patients with incurable confirmed hepatic primary or secondary tumours received a single cycle of LTLD, followed by ultrasound-mediated hyperthermia to a single target liver tumour. The primary endpoint relates to evidencing enhanced delivery of doxorubicin from LTLD at the target tumour site, by comparing intratumoural concentrations of the drug before and after focused ultrasound (FUS) exposure.

Detailed Description
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To date, purely pharmacological approaches have failed to address what is essentially a threefold challenge: (i) to deliver therapeutically significant concentrations of active agents to the tumour vasculature while minimizing off target effects; (ii) to release the therapeutic agent 'on-demand' at the target site; and, (iii) to improve the distribution and spread of the therapeutic agent against the intra-tumoural pressure gradient in order to achieve a therapeutically relevant concentration throughout the tumour. Recent pre-clinical studies performed at Oxford using ThermoDox® released using FUS has shown that increased uptake at the target site is achievable. Hence there is great promise in using this combination therapy to achieve increased tumour uptake and local dose for the equivalent dose of doxorubicin used in systemic chemotherapy for human subjects, which has a well established and safe toxicity profile. The first extracorporeal FUS device in Europe was used for a study performed at Oxford between 2002 and 2004. This single centre trial was sponsored by the University of Oxford. The recruiting study site was Oxford University Hospitals NHS Trust, where there is extensive clinical FUS experience. The study is split into two parts. Part I identified optimal FUS exposure parameters for a range of patient BMIs and tumour locations within the liver using real time thermometry data from an implanted thermistor. After at least 5 and no more than 14 participants have had the intervention using real-time thermometry, data was reviewed by the Trial Management Group (TMG) to confirm readiness to proceed without real-time thermometry. Part II, which did not require thermistor implantation, is designed to reflect how the therapy would be implemented in clinical practice. Participants received treatment for 1 day and are followed up for 30 days. All evaluable participants from both Part I and Part II were included in the endpoint analysis. Doxorubicin concentrations were directly determined from tissue biopsies of the target tumour, using a Good Laboratory Practice-validated high performance liquid chromatography (HPLC) assay, based on previously published methods. If this study demonstrates successful targeted drug delivery in human subjects using LTSLs released by mild-hyperthermia, this could potentially transform the future of chemotherapy in clinical practice; targeted therapy using LTSLs containing other chemotherapeutic agents triggered non-invasively by mild hyperthermia could be applied to any solid organ cancer.

Official Title
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A Proof of Concept Study to Investigate the Feasibility of Targeted Release of Doxorubicin From Lyso-thermosensitive Liposomal (LTSL) Doxorubicin (ThermoDox®) Using Focused Ultrasound in Patients With Primary or Secondary Liver Tumours

Conditions
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Liver Tumour

Intervention / Treatment
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* Drug: ThermoDox® (LTLD)
* Device: Focused Ultrasound of Target Liver Tumour
* Diagnostic Test: Pre-LTLD Biopsy of Target Liver Tumour
* Diagnostic Test: Post-LTLD Biopsy of Target Liver Tumour
* Diagnostic Test: Post-LTLD+FUS (Post-FUS) Biopsy of Target Liver Tumour
* Device: Thermometry of Target Tumour


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Pathologically confirmed advanced solid tumour with liver metastasis suitable for intervention (as assessed by ultrasound or other radiological methods). In addition confirmed primary liver tumours (hepatocellular carcinoma or cholangiocarcinoma) can be included. Will have progressed or remained stable on conventional chemotherapy. Male or Female, Age ≥ 18 years. Have life expectancy of ≥ 3 months. Left Ventricular Ejection Fraction (LVEF) ≥ 50% on echocardiogram. Have not received radiotherapy to the target area within the preceding 12 months. A World Health Organisation (WHO) performance status of ≤ 1 - Able and willing to give written informed consent, indicating that they are aware of the investigational nature of this study and potential risks, and able to comply with the protocol for the duration of the study, including scheduled follow-up visits and examinations. Exclusion Criteria: Have surgery or other procedure requiring general anaesthesia planned to be undertaken during the period of the study. Have serious illnesses including, but not limited to, congestive heart failure (NYHA class III or IV functional classification); life threatening cardiac arrhythmia; or myocardial infarction or cerebral vascular accident within the last 6 months. Have on going significant infection (chest, urine, blood, intra-abdominal). Have uncontrolled diabetes. Have Have received a life-time dose of doxorubicin > 450 mg/m2 or a life-time dose of epirubicin > 900 mg/m2 or any dose of both. Pregnant or breast-feeding. In women of childbearing potential, a negative pregnancy test (serum) is required within 30 days prior to study intervention. Female participants of child bearing potential and male participants whose partner is of child bearing potential who are not willing to practice an acceptable form of contraception (i.e. oral contraceptive, diaphragm, cervical cap, condom, surgical sterility) during the study and for 6 months thereafter. Women whose partner has or men who have undergone a vasectomy must use a second form of birth control. Have any known allergic reactions to any of the drugs or liposomal components or intravenous imaging agents to be used in this study. Have portal or hepatic vein tumour invasion/thrombosis. Inadequate haematological and biochemical function (as listed in protocol) Have contraindications to receiving doxorubicin including prior sensitivity (rash, dyspnoea, wheezing, urticarial or other symptoms) attributed to anthracyclines or other liposomal drugs. Use of chemotherapy or of an investigational drug within 30 days or 5 half-lives, whichever is longer, preceding the intervention. Have medically significant active infection. Have Child-Pugh Class C liver disease, or Class A-B with encephalopathy and/or refractory ascites. Documented HIV positive. Documented diagnosis of haemochromatosis. Documented history of contrast-induced nephropathy. Have any of the following contraindications for liver biopsy: Suspected liver haemangioma or other vascular tumour Tense ascites Known cystic liver disease* Extra-hepatic biliary obstruction* (* Relative contraindications only and may be non-exclusive at discretion of the study team) Other medical or psychiatric conditions or laboratory abnormalities that the investigator considers would make the patient a poor trial candidate.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Parts I and II of the study were not randomised, and both Parts of the study are detailed further in the published protocol summary, detailed in References section. After a minimum of 5 patients were treated in Part 1 (Arm 1), Part 2 (Arm 2) of the study could be opened.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Part I<br>All participants in Part I received: Pre-LTLD Biopsy of Target Liver Tumour ThermoDox® (LTLD) Post-LTLD Biopsy of Target Liver Tumour Focused Ultrasound of Target Liver Tumour Thermometry of Target Tumour Post-LTLD+FUS (Post-FUS) Biopsy of Target Liver Tumour Part I of the study was designed to identify optimal focused ultrasound (FUS) exposure parameters for a range of tumour locations within the liver, using real-time thermometry data from an implanted thermometry device (a thermistor or thermocouple). Plasma and biopsy samples of the target liver tumour were taken pre-LTLD, post-LTLD and post-LTLD+FUS. | Drug: ThermoDox® (LTLD)<br>* ThermoDox® (LTLD) infusion at a dose of 50mg/m2 whilst under general anaesthetic during intervention (Day 1)<br>* Other names: Lyso-thermosensitive Liposomal Doxorubicin;Device: Focused Ultrasound of Target Liver Tumour<br>* Whilst the ThermoDox® was circulating in the blood stream, the JC200 Therapeutic Ultrasound device was used to induce mild hyperthermia in a single (region of) a target liver tumour.<br>Diagnostic Test: Pre-LTLD Biopsy of Target Liver Tumour<br> <br> Diagnostic Test: Post-LTLD Biopsy of Target Liver Tumour<br> <br> Diagnostic Test: Post-LTLD+FUS (Post-FUS) Biopsy of Target Liver Tumour<br> <br> Device: Thermometry of Target Tumour<br>* A clinically approved thermistor or thermocouple was placed in the target liver tumour for real-time thermometry.<br>|
| Experimental: Part II<br>All participants in Part II received: ThermoDox® (LTLD) Focused Ultrasound of Target Liver Tumour Post-LTLD Biopsy of Target Liver Tumour Following a minimum of 5 Part I cases, and subject to Trial Management Group approval, Part II of the study was opened to run in parallel to Part I. Part II did not require implantation of a thermometry device, and instead used predictions from Part I data to set the FUS parameters. Targeted drug delivery in Part II thus proceeded completely non-invasively, and this part of the study was designed to more closely reflect how the therapy might be implemented in routine clinical practice. Plasma samples were taken pre-LTLD, post-LTLD and post-LTLD+FUS. Biopsy samples of the target liver tumour were taken only post-LTLD+FUS. | Drug: ThermoDox® (LTLD)<br>* ThermoDox® (LTLD) infusion at a dose of 50mg/m2 whilst under general anaesthetic during intervention (Day 1)<br>* Other names: Lyso-thermosensitive Liposomal Doxorubicin;Device: Focused Ultrasound of Target Liver Tumour<br>* Whilst the ThermoDox® was circulating in the blood stream, the JC200 Therapeutic Ultrasound device was used to induce mild hyperthermia in a single (region of) a target liver tumour.<br>Diagnostic Test: Post-LTLD+FUS (Post-FUS) Biopsy of Target Liver Tumour<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Concentration of Total Intratumoral Doxorubicin in Liver Tumour (Biopsies) Following Targeted Release of Doxorubicin From ThermoDox® ('Drug') Using Mild Hyperthermia Generated Non-invasively by Focused Ultrasound (FUS) | Analytical chemistry (High Performance Liquid Chromatography) for total doxorubicin (including both released and unreleased forms) was performed on section of intratumoral biopsy samples in Good Clinical Practice Laboratory, using a validated assay. Doxorubicin concentration was evaluated in biopsy samples both post-LTLD and post-LTLD+FUS. Tumour samples were not analysed same day and were frozen at -80^oC for subsequent analysis. Required to evaluate the primary endpoint. | Post-intervention sample (Day 1) compared to pre-intervention sample (Day 1) | 
| Patients Demonstrating >Two-fold Increase in the Amount of Intratumoural Doxorubicin Before and After Focused Ultrasound | To satisfy the primary endpoint, a demonstrable two-fold increase in*, or value exceeding 10μg/g of, the concentration of intra-tumoural doxorubicin at the treated tumour site following FUS-induced mild hyperthermia, was required in at least 50% of evaluable participants. * As per the a priori protocol design, in Part II the biopsy prior to FUS-induced mild hyperthermia is not performed and therefore the average value for all evaluable tumours receiving intervention in Part I is used as a comparison for the two-fold increase from pre-FUS to post-FUS biopsy. | Post-LTLD+FUS sample (Day 1) compared to Post-LTLD sample (Day 1) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| (Part I Only) Achievement of Satisfactory Hyperthermia Within the Target Liver Tumour for a Range of Participant Body Mass Indices (BMIs) and Tumour Locations Within the Liver (Optimal FUS Exposure Parameters) | Achievement of hyperthermia in the target liver tumour, as determined by real-time thermometry obtained by an indwelling thermometry device. For success, sustained and controlled hyperthermia is required in the target tumour, consequent with drug release (in excess of 39.5^oC). Real time thermometry plots for each Part I patient are available in the key Lancet Oncology publication, details available in the References section. | Real-time thermometry monitoring during intervention (Day 1) | 
| Persistence of Cell Viability Stain Post-LTLD+FUS | Post-LTLD+FUS tissue from the targeted liver tumours was obtained by biopsy at the time of the intervention, between 24/03/2015 and 29/03/2017. Cytokeratin-8 (CK-8) is a cell viability marker which if present, demonstrates lack of ablative cell death by any ablative modality, including FUS. Not all histological cell types express CK8, thus if the Post-LTLD+FUS it may either indicate: i) Non-CK8 expression ii) Thermal ablation and consequent cell death. Note there was uncertainty about CK8 expression of individual patient tumours prior to recruitment. In this study if the Post-LTLD+FUS tissue shows specific cellular CK8 cellular staining, then it demonstrates that i) the tumour is CK8+, and, ii) the tumour was not instantaneously thermally ablated and any subsequent cell death is likely due to drug delivery/chemo-ablation. For more information see key TARDOX Lancet Oncology publication and Cytokeratin 8 reference (both detailed in References section). | Tissue obtained on day of intervention (Day 1). All CK8 cell viability staining was performed within 2 months of sampling. | 
| Patients With Significant (Grade 3-5) Adverse Event(s) Deemed Related to ThermoDox (LTLD) | Adverse Events are listed separately in the subsequent results, but were also specified as a secondary endpoint in the a priori protocol and thus significant events are summarised here. 'Definitely' or 'Probably' related events are included. | Up to 30 days post-intervention (Day 1-30) | 
| Patients With Significant (Grade 3-5) Adverse Event(s) Deemed Related to FUS Procedure | Adverse Events are listed separately in the subsequent results, but were also specified as a secondary endpoint in the a priori protocol and thus significant events are summarised here. 'Definitely' or 'Probably' related events are included. | Up to 30 days post-intervention (Day 1-30) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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ThermoDox, High Intensity Focused Ultrasound, Lyso thermosensitive Liposomal, Non invasive drug delivery, Hepatic metastatic disease, Liver tumour(s), Targeted Release of Chemotherapy