phase ii study of recombinant interleukin la and etoposide ......1722 il-la and etoposide in...

Vol. 3, 1 721-1729, October /997 Clinical Cancer Research 1721

3 The abbreviations used are: OS, osteosarcoma; IL, interleukin: PR,

partial response; TNF-a, tumor necrosis factor a; NO, nitric oxide.

Phase II Study of Recombinant Interleukin la and Etoposide in

Patients with Relapsed Osteosarcoma 1

Laura L. Worth, Norman Jaffe,

Robert S. Benjamin, Nicholas E. Papadopoulos,

Shreyaskar Patel, A. Kevin Raymond,

Shu-Fang Jia, Carlos Rodriguez, Jacalyn Gano,

Mary Ann Gianan, and Eugenie S. Kleinerman2

Departments of Pediatrics IL. L. W., N. J., E. S. K.I, Cell Biology

[S-F. J., C. R., J. G., M. A. G., E. S. K.], Pathology IA. K. RI. andMedical Oncology [R. S. B., N. E. P. S. P.1, The University of Texas

M. D. Anderson Cancer Center, Houston, Texas 77030

ABSTRACT

A Phase II trial using interleukin hi (IL-la) and eto-poside for patients with relapsed osteosarcoma (OS) was

undertaken to assess the feasibility and tolerability of corn-bination therapy with biotherapy and chemotherapy. Nine

patients with histologically proven relapsed OS were treated

with IL-la immediately followed by etoposide daily for 5

days every 3 weeks. Surgical resection of lung metastasis or

peripheral tumor was performed after two or three cycles.We observed three partial responses; disease was stable inanother case. One case could not be evaluated. The sideeffects associated with combination therapy were as pre-

dicted from known side effects of the individual agents;

however, more profound neutropenia was observed. Four

patients exhibited clinical signs of capillary leak syndrome,

i.e., hypotension, edema, and weight gain. The etiology of the

capillary leak was unclear, because serum IL-la, IL-2, tu-mor necrosis factor, and nitric oxide levels could not be usedto predict which patients would develop capillary leak. His-tological analysis of tumor specimens obtained after two or

more courses of therapy showed changes consistent with a

response to a biological response modifier: peripheral fibro-

sis surrounded the metastasis with infiltration of chronic

and acute inflammatory cells. Because the response of Fe-lapsed OS to any type of salvage regimen has been poor, we

interpret the clinical response of this therapy as good. How-ever, the significant side effects associated with this therapy

must also be taken into consideration before deciding to use

Received 4/30/97: revised 7/1/97: accepted 7/8/97.The costs of publication of this article were defrayed in part by thepayment of page charges. This article must therefore be hereby marked

advertisement in accordance with 18 U.S.C. Section 1734 solely to

indicate this fact.

I Supported in part by Grants CA-l7772, CA-42992, and CA-66632.

Also supported by a grant from the Gillson-Longenbaugh Foundation

(to E. S. K.).2 To whom requests for reprints should be addressed. at Department of

Cell Biology, Box 173, The University ofTexas M. D. Anderson CancerCenter, 1515 Holcombe Boulevard, Houston, TX 77030. Phone: (713)

792-81 10: Fax: (713) 792-8747.

this combination therapy. It is unfortunate that the study

was stopped early due to halted production of IL-la. If this

agent is again manufactured for clinical use, we conclude

that additional evaluation in patients with relapsed OS iswarranted.

INTRODUCTION

The majority of patients with OS� have subclinical pulmo-

nary micrometastases at the time of initial presentation and

diagnosis. Surgical resection of the primary tumor coupled with

intensive adjuvant chemotherapy has improved the metastasis-

free survival rate from less than 20% at 2 years to 60% at S years

( 1-3). However, 30-40% of these patients still die of pulmo-

nary metastases that are resistant to conventional therapy (2-4).

The majority of patients experience a relapse within the first 2

years, either while receiving adjuvant chemotherapy or shortly

after the completion of chemotherapy. The prognosis for these

patients is poor. Although the metastases can be removed by

surgery, 70-85% will recur within 1 year (2-4). Several che-

motherapeutic agents, different from those used in the initial

therapy, are being studied in an attempt to develop more effec-

tive therapy.

One agent that has been studied is etoposide, an intracel-

lular poison that acts by stabilizing the cleavable complex

between topoisomerase II and DNA. The drug-topoisomerase II

DNA complex formation initiates a series of intracellular events

culminating in the death of the cell (5). The experience with

etoposide used as a single agent in relapsed OS is limited. A

Pediatric Oncology Group study (6) analyzed the effect of

etoposide when ISO mg/m2/day were given IV for 3 days every

3 weeks. Of the 1 1 patients studied, I PR and 1 minor response

were observed. Consequently, etoposide as a single agent is not

considered active against relapsed OS.

IL-l is primarily a monocyte/macrophage product pro-

duced in response to infection, injury, or immune challenge.

Among its numerous biological activities are inducing other

cytokines [e.g., IL-2, IL-6, colony-stimulating factors, TNF, and

intracellular adhesion molecules (7-9)] and activating T and B

lymphocytes (10-12). It also enhances the ability of lympho-

cytes to bind and kill tumor cells (13). In melanoma cells, a

synergistic interaction between IL- I a and etoposide has been

reported (14).

Recent studies (IS, 16) demonstrated that IL-la enhanced

the in vitro cytotoxicity of etoposide. In three different human

OS cell lines with relative resistance to etoposide, use of IL- 1a

increased the cytostatic activity of etoposide from 9% to 70%.

The synergistic activity was only demonstrated when IL-la

incubation preceded or coincided with etoposide. When etopo-

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1722 IL-la and Etoposide in Relapsed Osteosarcoma

entry.

Table I Patient characteristics

Metastasis

Zubrod Pathological Primary at PriorPatient score Age Race” Sex disease subtype disease site diagnosis chemotherapy” Responsec

1 1 15 H F Fibroblastic Femur + ifx Mtx

CDDP Ad/iaPR

2 1 17 W M Osteoblastic Femur - ifx MtxCDDP Adriaetop thio

hycamp

Inevaluable

3 0 32 W F Dedifferentiated

paraostealFemur - ifx CDDP

Adria TaxolSD

4 0 17 W F Chondroblastic Femur - ifx Mtx

CDDP Adriableo CytActD Etop

Mixed

5 2 18 B F Osteoblastic Tibia - ifx Mtx

CDDP AdriaPD

6 1 3 1 H M Chondroblastic Hard palate - ifx Mtx

CDDP Ad/iaTaxol

Mixed

7 0 43 A F Fibroblastic Femur - ifx MtxCDDP AdriaTaxol DTIC

PR

8 0 14 H M Osteoblastic Femur - ifx Mtx

CDDP AdriaPR

9 0 19 W M Not specified Femur - ifx Mtx

CDDP Ad/iacarbo hycamp

PD

white; B, black; A, Asian.“ H, Hispanic; W,I’ ifx, ifosfamide; Mtx, methotrexate; CDDP, cisplatin; Adria, doxorubicin; etop, etoposide; thio, thioguanine; hycamp, hycamptamine; bleo,

bleomycin; taxol, paclitaxel; cyt, cyclophosphamide; ActD, dactinomycin; DTIC, dacarbazine: carbo, carboplatin.

‘ PR, partial response; SD. stable disease; PD, progressive disease.

side incubation preceded IL-la, no synergy was seen (15). This

clinical trial study was undertaken to assess the feasibility of

combination IL-la and etoposide therapy and its efficacy in

patients with relapsed OS.

PATIENTS AND METHODS

The characteristics of the patients in this trial are summa-

rized in Table I . Nine patients were enrolled in this study

between April and September 1994. The median age of the S

female and four male patients was 18 years. All patients had

resection of the primary tumor and received prior therapy with

ifosfamide, cisplatin, and doxorubicin; all but 1 (patient 3) also

received high-dose methotrexate. These four drugs are the most

effective agents currently in use against OS. Six patients also

received additional chemotherapeutic agents, including etopo-

side, carboplatin, dacarbazine, bleomycin, cyclophosphamide,

thioguanine, paclitaxel, and hycamptamine. OS recurred in the

lung (eight cases), primary site (three cases), mediastinum (one

case), humerus (one case), and paraspinal area (one case). Two

patients (patients 4 and 6) received prior radiotherapy. None of

the patients received any prior immunotherapy.

Eligibility criteria included the following: (a) patients from

S to 70 years of age with histologically proven OS in whom

standard therapy was not effective; (b) measurable disease; (c)

an estimated life span � I 2 weeks and a Zubrod performance

status of 0-2; and (d) no chemotherapy, immunotherapy, hor-

monal therapy, or radiation therapy within 3 weeks of study

Patients were excluded if they had any serious intercurrent

illness, had received more than one biological response modi-

fier, or had significant cardiovascular disease. All patients gave

written informed consent to participate in the study in accord-

ance with established guidelines from the Surveillance Commit-

tee at M. D. Anderson Cancer Center.

Drugs. Recombinant IL-la was supplied by the Drug

Management and Authorization Section, Cancer Therapy and

Evaluation Program, National Cancer Institute. Each lOO-p.g

vial of sterile, white, preservative-free, lyophilized powder also

contained 10 p� of human serum albumin. The compound was

reconstituted in S ml of 0.9% sodium chloride for injection,

USP, and was stable 24 h after reconstitution.

Treatment Plan. IL- la (0. 1 p.glkg/day) was adminis-

tered s.c., followed immediately by iv. administration of

etoposide (100 mg/m2) via central venous catheter over 3 h.

Patient intake and output were strictly monitored. In the

hemodynamically stable patient, vital signs were measured

hourly for 3 h and then every 4 h. In patients experiencing

hypotension or other side effects, vital signs were monitored

every 5-15 mm until the patient was hemodynamically sta-

ble. Hemograms were monitored twice weekly; chemistries

(i.e., electrolytes and liver function tests) and urinalysis were

monitored weekly. IL-Ia and etoposide were given daily for

S days every 3 weeks. Patients were monitored with the

appropriate X-ray studies prior to each course of treatment.

Surgical resection of lung metastases or peripheral tumors

was performed after two or three courses.



Clinical Cancer Research 1723

Efficacy. Disease was assessed after two courses using

standard response criteria. Disappearance of all evidence of a

tumor for at least one cycle (4 weeks) with resolution of all

symptoms associated with the tumor constituted complete re-

sponse. A greater than 50% decrease in the sum of the diameters

of all measured lesions for more than one cycle (4 weeks) and

no new lesions or increase in size of any lesion constituted a PR.

Minor response was defined by a less than 50% decrease in the

diameters of all measured lesions for more than one cycle. A

greater than 25% increase in the sum of the diameters of

measurable lesions or estimated nonmeasurable lesions was

considered progressive disease. Responses based on tumor ne-

crosis were defined as �90% necrosis, complete response;

60-89% necrosis, PR; and < 60% necrosis, stable disease.

Every attempt was made to give three courses of treatment and

evaluate tumor response histologically.

Cytokine Analysis. Serial blood samples were collected

at different times during the first course of combination therapy

in standard hematology collection tubes (plasma), stored at 4#{176}C,

and processed within 1-2 h of collection. Aliquots of plasma

were stored at -70#{176}C.

Serum IL-la, IL-2, and TNF-a levels were measured using

a solid-phase sandwich ELISA kit [Biotrak, obtained from

Amersham International, Poole, United Kingdom (for IL-la) or

from Biosource International, Camarillo, CA (for IL-2 and

TNF-a)] following manufacturers’ recommendations.

NO produced by the body is rapidly oxidized to nitrate and

nitrite. These products were reduced to nitric oxide in vanadium

chloride and measured in a nitric oxide chemiluminescence

analyzer (Sievers Instruments, Boulder, CO). Values were de-

termined by comparison against a standard curve.

RESULTS

Unfortunately, the study had to be closed prematurely

when IL-i-a was no longer available for clinical use due to

supply problems.

Clinical Toxic Side Effects. The clinical side effects

associated with IL-la and etoposide therapy are outlined in

Table 2. One patient (patient 2) had a severe reaction after

receiving the first dose of the first course of IL- la and etopo-

side. He developed respiratory distress with tachypnea, an in-

crease in oxygen requirement, and facial and upper extremity

edema. His symptoms resolved with furosemide, diphenhydra-

mine, and decadron. The severity of the reaction caused the

patient to be taken off the protocol. Thus, only the data from the

remaining eight patients are analyzed. A total of 35 courses of

IL-la and etoposide (range, 2-9; median, 4; and mean, 4.4)

were given to these eight patients. The side effects and toxicities

of the etoposide and IL- la together were as predicted from the

known side effects of the individual agents. More than 75% of

the courses were associated with fever, chills, vomiting, head-

ache, fatigue, myalgias, and alopecia. More than 90% (32 of 35)

of the courses were associated with hypotension. More than

60% of the patients who experienced hypotension required

intervention for the condition. Most cases of hypotension were

managed with fluid therapy; however, two cases required blood

pressure support with dopamine to maintain systolic blood pres-

sures greater than 80 mm Hg.

Table 2 Toxicities asso ciated wit h IL- Ia and etoposide therapy

Toxicity Grade 1 Grade 2 Grade 3 Grade 4

Anemia 0 9 24 2

Thrombocytopenia 1 2 3 24

Neutropenia 0 0 0 35

Infection 16 0 7 1

Hypotension 13 17 2 0

Chills 0 26 8 0

Drug fever 2 28 5 0

Fatigue 5 10 8 0

Myalgia 4 15 0 0

Local skin reaction 9 1 0 0

Headache 4 20 4 N/A

Nausea 6 14 1 N/A

Vomiting 8 19 6 0

Diarrhea 2 4 0 0

Anorexia 9 17 3 0

Alopecia 0 32 N/A N/A

Stomatitis 7 8 3 0

Capillary leak syndrome 0 5 0 0

Creatinine elevation 1 1 0 0

Bilirubin elevation 0 4 4 3

Aspartate 5 2 3 0

aminotransferase

elevation

All courses of etoposide and IL-la were associated with

anemia of varying grades. Nine courses produced grade 2 ane-

mia; patients received 0-4 units of packed RBCs. In the 24

courses associated with grade 3 anemia, one-third did not re-

quire transfusions. The other courses required transfusion with

1-7 units of packed RBCs. Only two courses were associated

with grade 4 anemia; 4 and 6 units of packed RBCs were

transfused under these conditions. Two-thirds of the courses of

IL-la and etoposide produced thrombocytopenia with platelet

counts less than 25,000/mm3 (grade 4). Two-thirds of these

courses required platelet transfusions (4-60 units). All 35

courses of chemotherapy were associated with lowered absolute

granulocyte counts with nadirs less than 0.5/mm3. One patient

(patient 1) had an etoposide dose reduction of 25% for the

second course and of 50% for the third course secondary to

prolonged neutropenia and severe mucositis. The dose was

raised back to 100% for subsequent courses.

A significant therapy complication was fever and neutro-

penia that required hospitalization in 1 6 of the 35 courses. These

patients received iv. antibiotics until blood cultures were neg-

ative for at least 48 h, fever defervesced, and neutrophil counts

began to rise. In an additional 20% of the courses, the neutro-

penia was associated with blood cultures positive for Kiebsiella

pneumonia (two cases), Escherichia coli (two cases), Proteus

inirabilis (one case), Brahhamella catarrhalis (one case), Staph-

ylococcus hominis (one case), and a-hemolytic streptococcus

(one case). One patient in this group delayed seeking medical

attention despite known fever and neutropenia. Septic shock was

caused by Escherichia co/i and a-hemolytic streptococcus, re-

sulting in the death of the patient.

Less frequent complications included stomatitis, diarrhea,

and elevations in levels of serum bilirubin, aspartate aminotrans-

ferase, and creatinine. In 25% of the courses, local reactions at

the site of injection were noted.




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30

20

10

0

Time (hours)

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2000

1000

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-1000#{149}

Fig. 2 Plasma levels of TNF-a following the

administration of IL-la and etoposide. Blood

samples were collected from patients 2-9 at

various times after etoposide and IL-la admin-

istration. Plasma was separated, frozen at

-70#{176}C. and subsequently assayed for TNF-a.

S

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Capillary leak syndrome was associated with five courses

of chemotherapy in four patients. These patients exhibited

edema and weight gain of less than 10 pounds. These symptoms

resolved readily following the administration of furosemide.

Plasma Cytokines Induced following IL-la and Etopo-

side Administration. We obtained and analyzed plasma from

eight patients during their first course of treatment. Serum IL-la

Time (hours)

was not detectable in any patient prior to s.c. therapy. Beginning

1 h after treatment, IL-la levels were detectable; they peaked

3-4 h after administration and returned to baseline by 24 h (Fig.

1). Because IL-la has been shown to induce the production of

TNF-a, we also quantified changes in levels of plasma TNF-a.

As shown in Fig. 2, there was no consistent increase in the levels

of plasma TNF-a in any of the patients. Indeed, decreased

E

z

c)

Fig. 1 Plasma IL-la levels following the admin-

istration of IL-la and etoposide. Blood samples

were collected from patients 2-9 at various times

after etoposide and IL- la administration. Plasma

was separated, frozen at -70#{176}C, and subsequently

assayed for IL-la.



200

175

150

125

100

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75

50

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0 2 4 24 72 96

Time (hours)

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Fig. 3 Plasma levels of IL-2 following the ad-

ministration of IL-la and etoposide. Blood sam-

ples were collected from patients 2-9 at various

times after etoposide and IL- la administration.

Plasma was fractionated, separated, frozen at-70#{176}C,and subsequently assayed for IL-2. Notethat plasma samples from patient 2 were col-lected during an episode of capillary leak.

0U

z

30

20

10

0

Fig. 4 Plasma levels of NO following the ad-ministration of IL-la and etoposide. Blood sam-

ples were collected from patients 2-9 at various

times after etoposide and IL-la administration.

Plasma was separated, frozen at - 70#{176}C,and sub-sequently assayed for NO. Note that plasma sam-

ples from patient 2 were collected during an epi-

sode of capillary leak.

Time (hours)

plasma TNF-a levels were seen in five of eight patients follow-

ing combination therapy.

The etiology underlying the capillary leak syndrome seen

in four patients was also examined. IL-2 and NO have been

associated with hypotension and peripheral capillary leak syn-

drome. Therefore, patient plasma samples were also examined

for levels of IL-2 and NO. Figs. 3 and 4 illustrate that there was

no correlation between plasma IL-2 or NO levels and the de-

velopment of hypotension and edema following IL-la and

etoposide therapy. Significant increases in plasma IL-2 were

only seen in patients 3 and 5. Capillary leak syndrome did not

develop in patient 3 but was apparent in patients 2, 4, and 5.



4 R�’J1 6894


Fig. S Chest radiographs ofpatient 1 . Studies were obtainedprior to (left panel) and after(right panel) two courses of eto-poside and IL- 1a. An increase is

seen in the metastasis in theright upper lobe. Decreases areseen in the size of the left mid-dle and upper lobe metastases.No new disease is seen.

Clinical Response. As mentioned earlier, an adverse re-

action after the initial dose of IL-la and etoposide prevented

one patient (patient 2) from being included in our evaluation. Of

the remaining eight patients, disease in three patients responded

partially to therapy. These patients received five to nine courses,

and their PR lasted for 6-8 months.

Patient 1 presented with bilateral pulmonary metastases.

After the patient received two courses of combination therapy,

a chest X-ray showed enlargement of the pulmonary mass on the

right and decreases in the size of several lesions on the left (Fig.

5). Initially, this case was classified as a mixed response. A

thoracotomy was performed after the second course of treatment

because of the confusing clinical picture and what was pre-

sumed to be an enlarging mass in the right lung. The operation

revealed a cavitated spherical cyst filled with fluid. Histologi-

cally the cystic mass (Fig. 6) was composed of cellular debris,

inflammatory cells, and granulation tissue, with small pockets of

viable tumor cells only at the peripheral rim of the cyst. There-

fore, we concluded that the radiographic expansion of the mass

was not due to tumor growth but rather was secondary to

collection of fluid and inflammatory elements within the cystic

lesion. In view of the shrinking lesions in the left lung and the

necrotic tumor cells in the right lesion, we classified the case as

a PR. This patient received two additional courses of combined

therapy, and the lesions in the left lung were surgically resected.

Here too, the histological examination revealed intralesional

hemorrhage, fragments of dishesive tumor with some viable

tumor cells, and moderate infiltration with both acute and

chronic inflammatory cells. The findings are not typical of those

seen with chemotherapy in which the metastatic lesion has

central necrosis surrounded by a rim of viable tumor cells

growing into compressed normal lung tissue ( I 7).

The second patient (patient 7) to achieve a PR underwent

surgical resection of nodules in the right lung after three courses

oftherapy. On the basis of results from radiographic studies, this

patient’s disease was classified as stable. Histological examina-

tion of the tumor mass showed greater than 80% necrosis. The

majority of what were interpreted initially as “viable” cells were

shown by immunohistochemical studies to be inflammatory in

origin. Consequently, the case was also classified as a PR based

on histological examination.

The final patient in the PR category (patient 8) also had

bilateral pulmonary metastases; one lesion was almost corn-

pletely resolved, and the others decreased in size with treatment.

This patient had a single surgical excision of the pulmonary

metastases after three courses of treatment. The remaining mass

showed liquefaction and necrosis. Some cell dropout suggestive

of a response to a therapeutic agent was noted. However, there

was cautery damage to the tissue, which made the interpretation

less conclusive.

Although mixed response is not a traditional category, parts

of tumors in two patients had dramatic responses. Patient 6 had

OS of the hard palate. At this patient’s entry into the study, the

tumor mass was pushing the tongue posteriorly, partially ob-

structing the aerodigestive tract and requiring tracheostomy and

gastrostomy. After three courses of chemotherapy, the intraoral

portion of the tumor had regressed sufficiently to allow the

patient to speak more clearly and swallow. On radiographic

studies, the tumor progressed anteriorly, compromising the optic

chiasm and resulting in progressive loss of vision in one eye.

The other patient in this category (patient 4) had metastatic

disease to the lung as well as to the humerus and surrounding

soft tissue. She underwent surgical resection after two courses of

IL- I a and etoposide to assess response to therapy; the decrease

in pulmonary disease was accompanied by increased disease

invasion of soft tissue around the humerus. Pathological speci-

mens of the pulmonary nodules obtained after two courses of

therapy contained more than 80% necrosis. The humeral in-

tramedullary disease had >90% necrosis; however, the ex-

tramedullary, soft tissue component only exhibited 60% necro-

sis. In this case too, one area of the tumor responded

dramatically to therapy, whereas in another area the response

was less impressive.

Patient 3, with previous rapidly progressive pulmonary

disease, exhibited stable disease when treated with IL-la and

etoposide.



�. .� -- . . � :�

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Fig. 6 Histological sections of

OS lung metastasis removed at-ter therapy with etoposide andIL-la in patient 1 . A, residual

tumor (T between brackets) and

underlying fibrosis (F) form athin rim at the interface between

normal lung (NL) and central

cystic cavity (CC; H&E; mag-nification, X40). B, “residualtumor” is made up of a heterog-enous mixture of elements. Thetumor itself, with the accompa-nying osseous matrix (solid ar-

rows), is composed of appar-ently unaffected neoplastic cellsand cells with significant degen-erative cytological changes, aswell as cell dropout (hollow ar-

rowheads). There is a mixed in-

flammatory infiltrate scattered

diffusely throughout the lesion

(Infi), and it includes lympho-cytes, plasma cells, histiocytes

(some hemosiderin laden), and

polymorphonuclear cells (H&E;magnification, x 100).

Two patients had progressive disease. Brain metastases

developed in one patient (patient 5) after the second course of

chemotherapy. This patient was removed from the protocol.

Lung disease developed in the other patient (patient 9) after the

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first course, but this patient received a second course, because

the disease had responded poorly to previous therapies; there

were essentially no other treatment modalities available. After

the second course, radiographic studies indicated some of the




pulmonary nodules responded to therapy with necrosis and

liquefaction, whereas other areas did not. Low pulmonary

reserve precluded this patient from being a candidate for

thoractomy.

DISCUSSION

Although we were unable to complete this Phase II trial

because IL-la became unavailable, we demonstrated that the

biotherapy-chemotherapy combination is feasible and tolerable.

The side effects associated with the study were predicted from

the known side effects of each agent. However, the profound

neutropenia was greater than that experienced when etoposide

was used as a single agent. Fever and neutropenia were signif-

icant side effects requiring hospitalization of the affected pa-

tients. Sixteen of the 35 courses were associated with fever,

neutropenia, and blood cultures negative for bacteria. Seven

courses (20%) were associated with positive blood cultures in

addition to neutropenia. The profound neutropenia may be ex-

plained by the higher median daily area under the curve and

lower clearance rates quantified in patients receiving combina-

tion IL-Ia and etoposide compared with those values reported

when etoposide is administered alone (18). Alternatively, the

synergistic interaction that caused increased tumor killing of

cells may also have caused increased killing of bone marrow

cells. Only one patient required reduction in etoposide dose (for

two courses); it was restored to 100% for the remainder of the

courses.

Four patients in five courses of therapy had symptoms

suggestive of peripheral capillary leak syndrome (hypotension,

edema, and weight gain). Serum levels ofthe proteins associated

with this syndrome (IL-l , IL-2, and TNF-a) and NO were not

helpful in predicting which patients would develop capillary

leak. The factors involved in the development of this syndrome

are still unclear.

A difficult problem in analyzing tumor response to a bio-

logical response modifier is measuring the clinical response to

the therapy. In situations in which cytokines are administered or

their release is stimulated, an inflammatory reaction can be

initiated. By conventional radiography, this inflammatory prod-

ess can appear as an enlarging tumor mass and be interpreted as

worsening disease. Consequently, evaluating the results of

chemotherapy plus biological response modifiers against meta-

static lung disease by use of a chest radiograph may not truly

represent what is happening on the cellular level. In several

patients, an inflammatory response was initiated that resulted in

fluid accumulation either as a cystic mass surrounding the

metastatic nodules or actually replacing the disease. If a lesion

is partially filled with fluid, an air-fluid level can be appreciated

and may differentiate such a mass from an enlarging metastasis.

When results of therapy were not clear, surgery was performed

without waiting for the third course of chemotherapy to be

completed. We correlated the histological characteristics of

these enlarging metastatic lesions with their appearance on

nuclear magnetic imaging scans to better interpret the effects of

therapy.

For most patients, the time needed to recover from thoracic

surgery was usually 2 weeks. Consequently, the time interval

between courses of etoposide and IL-la was 6 to 8 weeks. Two

patients had two surgical procedures between courses of chem-

otherapy (sequential thoracotomies and thoracotomy followed

by hemipelvectomy). For these patients, the time between

courses of chemotherapy when separated by two surgical pro-

cedures approached 3.5 months. During this interval without

therapy, it was not uncommon for the tumor that had been

responding to chemotherapy to begin to grow again.

Because the response of relapsed OS to any type of salvage

regimen has been poor, we interpreted the clinical response to

this therapy as good, with three PRs and one case of stable

disease in eight patients. All four patients had previously failed

a number of salvage regimens in addition to their front-line

chemotherapy. If the assessment of the response to therapy were

determined by more conventional methods, using only radio-

graphic evidence, than only one patient would be considered to

have had a PR. Judged by traditional criteria, this therapy would

have the same overall outcome as in the Phase II study evalu-

ating etoposide as a single agent (6). However, biological re-

sponse modifiers, such as IL-la, act by stimulating the immune

system, enhancing the cytotoxic activity of agents, and inhibit-

ing angiogenesis (19). Consequently, determining the response

rate using only radiographic evidence when there is a mass

effect from inflammation and hemorrhage could result in un-

derestimation of response and the possible elimination of a

potentially useful combination therapy. Under strict criteria, the

mixed response category is considered progressive disease.

However, it was a distinct category in this study because parts

of two patients’ tumors showed response to therapy. In the

patient with metastatic disease to the humerus that extended into

the adjacent soft tissue, the intramedullary disease showed

greater than 90% necrosis histologically. She had no therapy for

4 weeks before beginning IL-la and etoposide; thus this necro-

sis is unlikely to have been the result of prior therapy. The soft

tissue disease failed to respond to therapy. For the patient with

OS of the hard palate, tumor regression restored the ability to

speak more clearly and eat again; this was a welcome relief and

a dramatic response.

Halted production of IL-la caused this study to be stopped

prematurely. If this agent is again manufactured for clinical use,

we conclude that its further evaluation in patients with relapsed

OS is warranted. Although some side effects were significant

and need to be taken into consideration, the rate of disease

response in this study of combined biotherapy and chemother-

apy makes this approach promising.

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1997;3:1721-1729. Clin Cancer Res L L Worth, N Jaffe, R S Benjamin, et al. in patients with relapsed osteosarcoma.Phase II study of recombinant interleukin 1alpha and etoposide

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