ANTICANCER RESEARCH 31: 3921-3926 (2011)

ADH-1 in the Treatment of Metastatic - Case Report

NIRIT YAROM1, DAVID STEWART3, LEONARD AVRUCH1, RAJESH MALIK2, JULIE WELLS1 and DEREK J. JONKER1

1The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada; 2Agennix Incorporated, Houston, TX, U.S.A.; 3MD Anderson Cancer Centre, Houston, TX, U.S.A.

Abstract. Adrenocortical Carcinoma (ACC) is rare with an AdrenoCortical Carcinoma (ACC) is a rare disease, with a annual incidence of 0.5-2 cases per million worldwide. Some worldwide annual incidence of 0.5-2 cases per million. It ACC tumors over express N-cadherin, which correlates with accounts for 0.04-0.2% of all cancer deaths(1). For advanced metastatic potential. ADH-1 (Exherin™) is a competitive unresectable disease, treatment improvements have been inhibitor of N-cadherin, resulting in rapid onset of tumor limited, and prognosis remains poor. In an attempt to vascular angiolysis and apoptosis in preclinical models. establish a treatment standard, there is currently an ongoing Targeting N-cadherin may cause direct anti-tumor and anti- international randomized phase III trial (FIRM-ACT) vascular effects. We report a case of ACC with benefit from comparing , , plus mitotane vs. ADH-1 therapy. A 24 year old woman with an N-cadherin plus mitotane (2). In addition, recently expressing metastatic ACC was treated on a phase I trial and published case reports have described beneficial effects of treated with ADH-1 subsequently received additional doses biological agents in individuals with this disease (3). through a special access program. The patient presented with In view of the poor response to conventional cushingoid features from over-secretion and was there is a need for novel therapeutic agents. Cadherins diagnosed with metastatic ACC in January 2003. Tumor represent a novel target in cancer therapy. Many carcinomas progression followed treatment with a combination of overexpress N-cadherin, with concomitant down-regulation of doxorubicin, cisplatin and mitotane. In October 2003, as a E-cadherin (the cadherin switch). This phenomenon correlates part of a phase I she was treated with as a single with a phenotypic change termed the epithelial mesanchymal dose of ADH-1 at 150 mg/m2. This resulted in transient transition (EMT) and with acquired tumor invasiveness and normalization of cortisol, tumor necrosis on CT imaging, and metastatic potential. The cadherin switch has been observed reduction in tumor perfusion on DCE-MRI. Following in various types of cancers, including adrenal tumors (4, 5). It progression on several additional lines of chemotherapy, she is also thought that N-cadherin prevents ligand-induced was again treated with ADH-1 under a Special Access receptor internalization and down-regulation, resulting in Program (SAP). After 33 weekly doses (22 with 150 mg/m2 sustained (MAPK) signaling, thus promoting proliferation (6). and 11 with 300 mg/m2) radiographic tumor progression was With both tumor overexpression and association with tumor demonstrated and treatment discontinued. She survived 40 aggressiveness, cadherins represent an attractive novel target months with metastatic disease, dying 12 months after her for cancer therapy. last dose of ADH-1. This observation merits consideration for ADH-1 is a cyclic pentapeptide which contains the prospectively evaluating the efficacy of ADH-1 in patients cadherin cell adhesion recognition sequence His-Ala-Val and with cortisol secreting ACC that over express N-cadherin. competitively inhibits N-cadherin function, resulting in rapid onset of tumor vascular angiolysis and apoptosis in preclinical models. Targeting N-cadherin may cause direct anti-tumor and anti-vascular effects. Correspondence to: Nirit Yarom, 60 Ha’amakim, Ganey-Tikva, Previous reports showed that peptides containing this Israel 55900. Tel: +973 545619418, Fax: +972 89779714, e-mail: sequence disrupt cell adhesion, induce apoptosis, and alter [email protected]; [email protected] the intracellular distribution of h-catenin and actin in Key Words: Adrenocortical carcinoma, ADH-1, Dynamic contrast endothelial cells (6). enhancing magnetic resonance imaging (DCE-MRI), phase-I, N- Injection of ADH-1 into tumor-bearing mice has been cadherin. shown to induce angiolysis. ADH-1 damages tumor blood

0250-7005/2011 $2.00+.40 3921 ANTICANCER RESEARCH 31: 3921-3926 (2011) vessels, but not normal, mature blood vessels, and herewith Table I. Mean Ktrans (1/min) in the region of interest. Post treatment inhibits growth of breast, ovarian, colon and lung carcinomas there is an increase in the mean ktrans, suggesting increased vascular (7). ADH-1 results in a tumor specific local increase in blood permeability due to vascular disruption. vessel permeability that leads to highly synergistic effects Pre-treatment Post-treatment with conventional cytotoxic drugs such as (5). Even at very high doses, ADH-1 does not affect mature Right tumor 0.211 0.376 blood vessels, as shown in a preclinical rat toxicity model. Left tumor 0.273 0.356 ADH-1 is being studied in phase II trials in a variety of cancers, including esophageal, non-small cell lung, renal cell, and hepatocellular carcinomas (5). In murine melanoma xenografts, ADH-1 in combination measuring 12.5×10.0 cm with extensive necrosis, 8 mitoses with melphalan significantly reduced tumor growth up to 30- per 10 high power fields, invasion of the inferior vena cava fold over melphalan alone. ADH-1 enhancement of response (IVC), negative nodes, and a positive microscopic margin at to melphalan was associated with increased formation of the IVC. By the McFarlane system, disease was stage 3 (13). DNA adducts, increased apoptosis, and intracellular No adjuvant therapy was prescribed, and she was well signaling changes (8). until February 2003 when she experienced two weeks of dry In sixteen human patients with metastatic melanoma, cough without fever and mild left flank pain. CT scan including six patients who had not responded to melphalan confirmed recurrence in the abdomen and metastases in both alone, treatment with ADH-1 plus melphalan was associated lungs. Her cortisol levels were within normal limits. with promising activity. Within three months of treatment, She received 4 months treatment with combination eight patients had complete responses, two had partial , cisplatin, mitotane, and with responses, two had stable disease, and four had progressive radiological clinical progression associated with increased disease (9). cushingoid features. The patient consented to a phase I clinical Results from two Phase I studies with ADH-1 have been trial with ADH-1, and her tumor was found to be positive for reported (10, 11). In both, ADH-1 was generally well N-cadherin expression. She received intravenous ADH-1 at a tolerated and the maximal tolerated dose (MTD) was not dose of 150 mg/m2. She developed transient normalization of reached. The most common adverse events at the doses used steroid hormones (Figure 1), increased disruption of blood were , fatigue, dysgeusia and hot flashes. Some vessels seen by increased permeability (k trans) on dynamic cardiovascular effects were seen but were thought to be contrast enhanced – magnetic resonance imaging (DCE-MRI) related, at least in part, to prior cardiac history and injection 90 min post ADH-1 (Table I and Figures 2 and 3) and rate. No responses or changes in blood flow were reported evidence of tumor necrosis on her six-week MRI scan. in patients with N-cadherin-negative tumors. Four patients However, according to the protocol she was withdrawned from with N-cadherin-positive tumors showed some evidence of the trial, since only patients responding by the World Health antitumor activity, including a PR in esophageal cancer. In Organiztion criteria were permitted to receive additional addition, phase I studies where ADH-1 is being evaluated in therapy. For the next year she was treated with various three separate combinations with , or (, , docetaxel, 5- are ongoing (12). , cisplatin, and doxorubicin) and modifiers of We report here for the first time the results of a young steroidogenesis (ketoconazole, aminoglutethemide and patient with metastatic ACC who was treated with ADH-1 mitotane) none of which yielded a sustained reduction of both as part of a clinical trial and subsequently through an cortisol levels. unrelated special access program (SAP). She subsequently was permitted to receive ADH-1 under an approved SAP and was treated with an additional 33 Case Report weekly doses (22 with 150 mg/m2 and 11 with 300 mg/m2). She tolerated the treatment well, with reported grade 1 In January 2002, a 22-year-old woman previously healthy nausea and . In addition, an episode of facial flashing presented with increasing abdominal pressure and occurred immediately after infusion of ADH-1. The patient discomfort. An ultrasound identified a mass in the left was hemodynamically stable and there were no associated adrenal gland measuring 10 cm which was displacing the symptoms. On another occasion she experienced chest spleen, pancreas and left kidney. There were no metastases discomfort occurring a few days after administration of seen. This was confirmed by MRI. A CT scan of her thorax ADH-1, thought to be possibly related. This was not and head showed no evidence of metastatic disease. She associated with dyspnea nor electrocardiogram (ECG) underwent an adrenalectomy. Histologic examination of the changes, with the discomfort resolving spontaneously resected mass revealed an adrenal cortical carcinoma (ACC) without intervention.

3922 Yarom et al: ADH-1 in the Treatment of Metastatic Adrenocortical Carcinoma

Figure 1. Plasma cortisol levels. ECF: Epirubicin cisplatin 5-fluorouracil; Tem/Gem: temozolomide gemcitabine; Doc: docetaxel; Fu: 5-fluorouracil; Cis/Etop: cisplatin etoposide.

While receiving the treatment the patient benefited from prolonged improvement of cortisol hypersecretion (Figure 1), and resolution of cushingoid features. By chest X-ray in December 2004 there was a minor response in the lung metastases. Throughout her ADH-1 SAP treatment the patient continued to take aminoglutethemide and took mitotane during the first 5 months of treatment until February 22, 2005. After 8 months of treatment the CT scan showed progression and the treatment was stopped. After progressing on ADH-1 she received oral etoposide and . She progressed on both treatments. The patient lived for 40 months from the diagnosis of metastatic disease and for 12 months after treatment with ADH-1 was stopped. This is compared (with the caveat of comparing to historical data) to a reported median survival Figure 2. Computed tomography (CT) scan through pelvis, showing two in stage IV ACC of 6-12 months only (14). masses.

Discussion a role for evaluation of agents such as IGF receptor inhibitors and antiangiogenetic drugs (15). N-cadherin is involved in the Adrenocortical carcinoma (ACC) is an extremely rare and development of malignant tumors of both the adrenal medulla aggressive disease. Data on the efficacy of systemic anti- and the . Information regarding expression of N- neoplastic treatments (mitotane and cytotoxic therapy) in the cadherin in ACC is very limited. In one study, 40% of adult treatment of advanced disease is limited. Currently an ongoing ACC had expression of N-cadherin (4). In contrast to the randomized international trial aims to define the best patient in this report, two reports show that N-cadherin is to combine with mitotane. Genetic and down-regulated in adrenal cortical tumors (4, 16). The authors biological studies have identified molecular targets, and suggest postulated that N-cadherin may be a tumor suppressor, which

3923 ANTICANCER RESEARCH 31: 3921-3926 (2011)

Figure 3. Pre- and post-treatment DCE-MRI. Post treatment there is an increase in the mean ktrans suggesting increased vascular permeability due to vascular disruption. Pre (A, C) and post (B, D) treatment dynamic contrast enhancing magnetic resonance imaging of the right (A, B) and left (C, D) tumors. when down-regulated leads to more aggressive behaviour of melanoma, with the combination of melphalan and ADH-1, the adrenocortical tumor. However, in other tumor types, N- half the patients achieved complete response (9). Our patient cadherin expression is increased – often de novo expression – had an aggressive and resistant tumor which was controlled with the concomitant down-regulation of E-cadherin (the metabolically and symptomatically only when the patient was cadherin switch). This phenomenon is correlated with acquired treated with ADH-1. Unfortunately her subjective and invasiveness and metastatic potential of cancer cells. Cadherin metabolic response did not translate into an objective tumor switching has been observed in various malignancies, including response. This raises the question of whether an alternate melanoma, breast and prostate cancer (5, 17). These findings method of response evaluation is required for biological agents, support N-cadherin as a therapeutic target. ADH-1 is a especially vascular-disrupting agents, one which evaluates the competitive inhibitor of N-cadherin function (6). In patients functional changes and not merely anatomical changes (18, where N-cadherin is expressed there are some reports of 19). Tumor blood flow change by DCE-MRI is a potentially response to ADH-1 (7, 8). In patients with locally advanced independent predictor of outcome when patients are treated

3924 Yarom et al: ADH-1 in the Treatment of Metastatic Adrenocortical Carcinoma with antiangiogenic agents (20). DCE-MRI is a non-invasive term effects of exherin on tumor vasculature. 2003 ASCO technique that records tissue perfusion, arterial input function Annual Meeting, 2003. (i.e. the concentration time course of contrast agent in the 8 Augustine CK, Yoshimoto Y, Gupta M, Zipfel PA, Selim MA, artery supplying the vascular bed), capillary surface area, Febbo P et al: Targeting N-cadherin enhances antitumor activity of cytotoxic therapies in melanoma treatment. Cancer Res capillary permeability (K-trans) and the volume of the 68(10): 3777-3784, 2008 . extracellular extravascular leakage space. DCE-MRI analysis 9 Tyler D. Regional therapeutic strategies in melanoma: not just generates parameters that can be used to measure abnormalities local disease control, but an opportunity to develop novel in tumor vessel flow, blood volume, permeability, tortuosity therapeutic strategies with potential implications for systemic and interstitial pressure (21). While receiving ADH-1 on the therapy. Ann Surg Oncol 15(11): 2987-2990, 2008. SAP, this patient received concurrent ‘conventional’ 10 Perotti A, Sessa C, Mancuso A, Noberasco C, Cresta S, Locatelli steroidogenensis-modifying therapy with mitotane and A et al: Clinical and pharmacological phase I evaluation of aminogluthetemide, making it difficult to decipher whether the Exherin (ADH-1), a selective anti-N-cadherin peptide in patients with N-cadherin-expressing solid tumors. Ann Oncol 20(4): 741- ADH-1 alone or its combination with the other agents were 745, 2009. responsible for the cortisol control over 8 months. Mitotane and 11 Stewart DJ, Jonker DJ, Goel R, Maroun JA, Cripps CM, Wells J, aminogluthetemide were administered before and after the Wargin W, Mallik RK and Peters WP: Final clinical and period when she received ADH-1 without disease control pharmacokinetic (PK) results from a phase 1 study of the novel suggesting attribution of the benefit to ADH-1 is appropriate. N- cadherin (N-cad) antagonist, Exherin (ADH-1), in patients ADH-1 might potentiate the efficacy of mitotane and with refractory solid tumors stratified according to N-cad aminogluthetemide. This coincides with other reports in the expression. 2006 ASCO Annual Meeting, 2006. 12 Siemann DW and Chaplin DJ: An update on the clinical literature that show that ADH-1 may potentiate and reverse development of drugs to disable tumor vasculature. Exp Opin resistance to conventional treatments (8, 9). Drug Discov 2(10): 1357-1367, 2007. ADH-1 toxicity was minimal, and is reported so even at 13 Macfarlane DA: Cancer of the adrenal cortex; the natural history, doses higher than used in this patient (10). prognosis and treatment in a study of fifty-five cases. Ann R Coll The patient presented in this report comprises a few Surg Engl 23(3): 155-186, 1958. unique characteristics; she had a rare disease with even a 14 Icard P CY, Andreassian B, Bernard A and Proye C: rarer expression of N-cadherin and at least subjectively Adrenocortical carcinoma in surgically treated patients: a retrospective study on 156 cases by the French Association of responded to a new N-cadherin antagonist. Although a rare Endocrine Surgery. Surgery 112(6): 972-980, 1992. condition, ADH-1 should be considered for further 15 Berruti A, Ferrero A, Sperone P, Daffara F, Reimondo G, Papotti evaluation in patients with advanced ACC who progressed M, Dogliotti L, Angeli A and Terzolo M: Emerging drugs for on conventional therapy if their tumors express N-cadherin. adrenocortical carcinoma. Expert Opin Emerg Drugs 13(3): 497- 509, 2008. References 16 Velazquez-Fernandez D, Laurell C, Geli J, Hoog A, Odeberg J, Kjellman M, Lundeberg J, Hamberger B, Nilsson P and 1 Kirschner LS: Emerging treatment strategies for adrenocortical Backdahl M: Expression profiling of adrenocortical neoplasms carcinoma: a new hope. J Clin Endocrinol Metab 91(1): 14-21, suggests a molecular signature of malignancy. Surgery 138(6): 2006. 1087-1094, 2005. 2 Fassnacht M and Allolio B: Clinical management of 17 Hazan RB, Qiao R, Keren R, Badano I and Suyama K: Cadherin adrenocortical carcinoma. Best Practice & Research Clinical switch in tumor progression. Ann NY Acad Sci 1014: 155-163, Endocrinology & Metabolism 23(2): 273-289, 2009. 2004. 3 Rini BI, Garcia JA, Cooney MM, Elson P, Tyler A, Beatty K, 18 Gaya AM and Rustin GJ: Vascular disrupting agents: a new class Bokar J, Mekhail T, Bukowski RM, Budd GT, Triozzi P, Borden of drug in cancer therapy. Clin Oncol (R Coll Radiol) 17(4): E, Ivy P, Chen HX, Dolwati A and Dreicer R: A phase I study of 277-290, 2005. sunitinib plus bevacizumab in advanced solid tumors. Clin 19 Kapse N and Goh V: Functional imaging of colorectal cancer: Cancer Res 15(19): 6277-6283, 2009. positron emission tomography, magnetic resonance imaging, and 4 Khorram-Manesh A, Ahlman H, Jansson S and Nilsson O: N- computed tomography. Clin Colorectal Cancer 8(2): 77-87, 2009. cadherin expression in adrenal tumors: up-regulation in 20 Flaherty KT, Rosen MA, Heitjan DF, Gallagher ML, Schwartz malignant pheochromocytoma and down-regulation in B, Schnall MD and O’Dwyer PJ: Pilot study of DCE-MRI to adrenocortical carcinoma. Endocr Pathol 13(2): 99-110, 2002. predict progression-free survival with sorafenib therapy in renal 5 Mariotti A, Perotti A, Sessa C and Ruegg C: N-cadherin as a cell carcinoma. Cancer Biol Ther 7(4): 496-501, 2008. therapeutic target in cancer. Expert Opin Investig Drugs 16(4): 21 O’Connor JP, Jackson A, Parker GJ and Jayson GC: DCE-MRI 451-465, 2007. biomarkers in the clinical evaluation of antiangiogenic and 6 Schmidmaier R and Baumann P: Anti-Adhesion evolves to a vascular disrupting agents. Br J Cancer 96(2): 189-195, 2007. promising therapeutic concept in oncology. Curr Med Chem 15(10): 978-990, 2008. Received August 6, 2011 7 Lepekhin E JX, Michaud S, Tonary A, Yu W, Symonds JM and Revised October 9, 2011 Blaschuk OW: Adherex Technologies Inc, editor. Early and long- Accepted October 10, 2011

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