A phase II study of outpatient subcutaneous histamine dihydrochloride, interleukin-2 and interferon-{alpha} in patients with metastatic melanoma

H. Schmidt1,+, S. Larsen2, L. Bastholt2, K. Fode1, C. Rytter1 and H. von der Maase1

1 Department of Oncology, Aarhus University Hospital, Aarhus; 2 Department of Oncology Odense University Hospital, Odense, Denmark

Received 25 March 2002 ; revised 30 April 2002, accepted 17 May 2002


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Background:

Experimental data had suggested a synergistic effect of histamine with interleukin-2 (IL-2) and interferon-{alpha} (IFN-{alpha}).

Patients and methods:

Forty-one patients with metastatic melanoma received IL-2 9 MU subcutaneously (s.c.) twice daily on days 4–8 and 25–29, and once daily on days 11–15 and 32–36. IFN-{alpha}-2b was given as 5 MU s.c. on days 1–3 and then daily to day 43. Histamine 1 mg s.c. was administered twice daily, following IL-2 and IFN injections starting on day 4. Efficacy and toxicity were compared with those of 42 patients included on exactly the same criteria and receiving the same regimen but without histamine.

Results:

Two patients achieved a partial response (PR) for an objective response rate of 5% [95% confidence interval (CI) 1% to 17%]. Median overall survival was 7.8 months (95% CI 6.4–9.1). In the control group, two complete responses and one PR were achieved. Median overall survival was 7.1 months (95% CI 5.4–8.9).

Conclusions:

This IL-2 and IFN regimen was well tolerated on an outpatient basis. However, the applied regimen cannot be recommended because of the low clinical efficacy. Histamine did not add efficacy or toxicity in combination with this moderate-dose schedule of IL-2 and IFN.

Key words: histamine, interferon-{alpha}, interleukin-2, metastatic melanoma, phase II


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Patients with metastatic malignant melanoma have a very unfavourable prognosis as <5% survive more than 2 years. Immune-modulating treatment with interleukin-2 (IL-2) induces long-term survival in a few patients. High-dose intravenous (i.v.) bolus schedules yield response rates of 16% with durable complete responses (CRs) in approximately one-third of the responders [1], but at the expense of significant toxicity for the majority of the patients. Combination regimens with interferon (IFN) and/or chemotherapy have been extensively evaluated in phase II studies and several large randomised trials are underway in Europe and the USA to confirm the encouraging results from some of these trials [2, 3]. However, most of these regimens are also associated with moderate to severe toxicity. Thus, it would be worthwhile to develop regimens that could be administered in an outpatient setting with maintained efficacy but less toxicity.

The present study deals with a new concept on how to increase the efficacy of IL-2 and IFN by the addition of histamine dihydrochloride. Tumour-infiltrating T lymphocytes and natural killer (NK) cells in melanoma metastases show signs of oxidative damage [4]. Macrophages and monocytes produce reactive oxygen metabolites, especially hydrogen peroxide [5], which effectively inhibits proliferation [6, 7] and cytotoxicity [8] of human NK cells in vitro. T cells and especially NK cells are susceptible to oxidative stress and eventually undergo apoptosis [9, 10]. Histamine, acting via H2-receptors on monocytes, inhibits formation and release of hydrogen peroxide in monocytes [5, 7, 11]. Histamine synergistically augments human NK-cell cytotoxicity in vitro during combined treatment with IFN [12] and IL-2 [8]. In vivo, combined treatment with histamine and IFN almost completely prevents development of melanoma B16/F10 lung metastases in mice, whereas IFN as monotherapy only modestly affects development of lung metastases [13]. Combined treatment with histamine and IL-2 synergistically eliminates melanoma B16 lung metastases in mice, whereas IL-2 as monotherapy is significantly less effective [13, 14]. Thus, histamine appears to be a very interesting drug for combination with IL-2 and IFN, but clinical experience is still limited. A small pilot trial was previously performed in metastatic melanoma [15].

The experimental data suggesting a synergistic effect of histamine with IL-2 and IFN inspired this phase II trial in metastatic melanoma. The primary object was to assess the objective response rate of this regimen as well as the duration of response. The secondary objective was to evaluate toxicity and survival.


    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Eligibility
The study was performed in the Departments of Oncology in Aarhus and Odense, Denmark. The eligibility criteria for this trial included the following: histologically confirmed metastatic malignant melanoma with measurable disease confirmed by physical examination or non-invasive radiographical procedures, age <70 years and WHO performance status of 2 or better. Exclusion criteria included central nervous system (CNS) metastases, major organ allografts, and other malignant disease other than in situ malignancies and basal cell or squamous cell carcinoma of the skin. Further exclusion criteria were symptomatic heart disease and acute myocardial infarction within 3 years, history of serious allergic disease and asthma, history of seizure disorders and serious psychiatric disease, and treatment with corticosteroids, ß- or H2-receptor blockers. Patients were not allowed to have received previously any systemic treatment for metastatic disease. Laboratory requirements included leukocytes >3.0 x 109/l, a platelet count >100 x 109/l and serum creatinine and bilirubin within 1.5 x upper limit of normal. Patients with a history of heavy smoking or lung disease were required to undergo a pulmonary function test and have a forced expiratory volume >70% of the predicted volume. The local Ethical Committee accepted this study and written informed consent was obtained from all patients.

Treatment plan
The treatment regimen consisted of IL-2 (Proleukin; Chiron Therapeutics, The Netherlands) at a flat dose of 9 MU subcutaneously (s.c.) twice daily on days 4–8 (Monday to Friday) and 25–29 (Monday to Friday) and once daily on days 11–15 and 32–36 (Monday to Friday). Patients also received IFN-{alpha}-2b (Introna; Schering-Plough, Denmark) at a flat dose of 5 MU s.c. on days 1–3 (Friday to Sunday) and then every day (Monday to Friday) to day 43. Histamine dihydrochloride (CepleneTM; Maxim, San Diego, CA, USA) was administered s.c. at a dose of 1 mg over 20 min, twice daily. Histamine injections were administered from day 4 and during the same days as IL-2 and IFN injections. Each treatment cycle was 70 days in length. Treatment was self-administered both in the inpatient unit for the weeks 1 and 4 and at home in the other weeks. The following medications could be given together with IL-2 and IFN: acetaminophen 1 g every 6 h, lansoprazole 30 mg in cases of dyspeptic problems, and i.v. or oral antiemetics (excluding corticosteroids) used at the discretion of the investigator.

Dose adjustments
Treatment with IFN was interrupted if leukocyte or platelet toxicity of grade 3 or greater occurred. All study drugs were withheld if CNS toxicity of grade 2 or greater or renal, hepatic or cardiovascular toxicity of grade 3 or greater occurred. Treatment was started again when the toxicity returned to grade 0 or 1. In the case of headache or symptomatic hypotension <90 mmHg, the injection time of histamine was increased to 30 min.

Treatment evaluation
All patients were required to undergo tumour staging that included a computerised tomography (CT) scan of the brain, chest and abdomen within 28 days before treatment. Blood samples, physical examination and ECG were performed in the week before treatment. All patients provided voluntary written informed consent to participate in this study. Patients had the following laboratory tests performed on days 1, 11, 15, 22, 32, 36 and 70: a complete blood count, creatinine, calcium and serum chemistry panel to include bilirubin, alanine aminotransferase, lactate dehydrogenase (LDH), alkaline phosphatase and prothrombin time. History and clinical examination were repeated after each treatment cycle. Toxicity was assessed with National Cancer Institute of Canada common toxicity criteria (version December 1994) on days 1, 4, 11, 25, 32 and 70 of each cycle. CT scans of the chest and abdomen for tumour measurements were repeated at the end of every cycle. Patients were treated with up to four cycles. To continue treatment after the first cycle, patients were allowed to have clinically insignificant progression of the disease. After the second cycle, patients with progression were discontinued. Patients had to have a WHO performance status of 2 or better to receive any treatment cycle.

Response criteria and statistical analysis
The clinical response was assessed using standard WHO criteria. A total accrual of 40 patients evaluable for response was intended. The design required initially 20 patients treated and then five patients for each response in the initial group. All patients who received one treatment cycle and patients who discontinued treatment during the first cycle because of progressive disease (PD) were evaluable for response. The duration of response was measured from day 1 of treatment to the date of PD, last follow-up date, or death from any cause. Survival was measured from day 1 of treatment to death or last follow-up. The estimate of survival curves was performed with the Kaplan–Meier method. The log-rank test was used to analyse survival differences among subgroups of patients. Follow-up was updated on 1 April 2002.

Controls
Comparative analyses of response, survival and toxicity were performed using a non-randomised control group treated exactly as the study group but without histamine. This group of patients was treated before the IL-2/IFN/histamine phase II trial was accepted and again after ending the protocol in the gap before a subsequent protocol. A total of 42 patients were treated from December 1998 to August 1999 and from January 2001 to May 2001 based on exactly the same inclusion criteria, response criteria and dose modifications as in the phase II trial. All data were collected prospectively.


    Results
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 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Between September 1999 and January 2001, 41 patients were enrolled in this phase II study (Table 1), including 24 males (58%) and 17 females (42%). The median age was 56 years (range 24–70). Nearly all patients (90%) had visceral metastases and 11 (27%) had liver metastases. Nineteen patients (46%) had an elevated LDH value before treatment.


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Table 1. Patient characteristics in the study group (n = 41)
 
Thirty-nine patients were assessable for response; two patients discontinued treatment on their own request within 2 weeks from the start of treatment and no response evaluation was performed. Two patients achieved a partial response (PR), one in liver metastases and the other in lymph node/lung metastases, for an overall response rate of 5% [95% confidence interval (CI) 1% to 17%]. The duration of these responses was 15 and 17 months. Five patients had no change and 32 patients progressed (Table 2). The median overall survival was 7.8 months (95% CI 6.4–9.1). At the time of the last follow-up, two patients (5%) were still alive at 27.1 and 30.6 months.


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Table 2. Response evaluation: study group [interleukin-2 (IL-2), interferon (IFN), histamine] versus the non-randomised control group (IL-2, IFN)
 
The non-randomised control group consisted of 42 patients, 21 males (50%) and 21 females (50%). Eight patients (19%) had liver metastases and 16 (38%) an elevated LDH value before treatment. No significant difference in the distribution of known prognostic factors between the control and the study group was noted (Table 3). In the control group, two CRs and one PR were seen with durations of responses of 10.1, 11.5+ and 12.6 months, respectively. The response rate was 7% (95% CI 2% to 20%) and responses were seen in skin, lymph node, lung and gastrointestinal metastases. The median overall survival was 7.1 months (95% CI 5.4–8.9). At the last follow-up, three patients were still alive at 13.1, 14.6 and 16.6 months. The two groups were largely medically untreated, as only two patients in the control group had previously received adjuvant IFN, with an interval of >3 months, and none in the histamine group.


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Table 3. Patient characteristics: study group [interleukin-2 (IL-2), interferon (IFN), histamine] versus the non-randomised control group (IL-2, IFN)
 
Toxicity
A total of 61 cycles were administered in the 41 study patients and 27 patients (66%) received full doses without delay. The dose was modified in 14 patients (34%), in five because of liver toxicity, in four due to disease progression, in two due to cardiological toxicity and in three due to other reasons. Biochemical toxicity was rare but a grade 3 rise in alkaline phosphatase was seen in four patients (10%). Only one patient (2%) experienced grade 3 anaemia. The most common non-biochemical grade 3 toxicity was lethargy in eight patients (20%) followed by cardiovascular and pulmonary toxicity in two patients (5%). Grade 3 altered hearing was observed in one patient due to the development of cerebral metastases. Grade 1–2 CNS toxicity comprised mostly mood changes and somnolence. No patient was discontinued due to toxicity and there were no treatment-related deaths. In three patients (7%), the injection time of histamine was increased from 20 to 30 min. Based on a total of >3500 histamine injections in 61 cycles, toxicity related to histamine was mainly transient flushing and a metallic taste, and otherwise negligible.

The toxicity in the control group was similar to that of the study group, as seen in Table 4. In this group, no patients were discontinued due to toxicity and there were no toxic deaths.


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Table 4. Toxicity: study group [interleukin-2 (IL-2), interferon (IFN), histamine] versus the non-randomised control group (IL-2, IFN). Grade (worst) according to National Cancer Institute of Canada common toxicity criteria
 

    Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
The question of the optimal dose and route of IL-2 administration alone or in combination with other cytokines remains unanswered. The substantial number of phase II IL-2 trials published use different routes of administration, dose schedules and combinations with other agents. No studies comparing i.v. administration with s.c. injections have been carried out in metastatic melanoma. Toxicity, however, seems to be lower after s.c. administration compared with i.v. administration and allows IL-2 to be given in an outpatient setting [1618]. The experimental data on histamine as an adjuvant to IL-2 [8, 13] and IFN [12] suggested a synergistic effect, which, together with the first clinical trial in metastatic melanoma [15], inspired this phase II study. However, the obtained response rate of only 5% and no lasting responses was disappointing. There was no indication that histamine did add efficacy to IL-2 and IFN. Similar results were seen in a recently published phase II trial with low-dose IL-2, IFN and histamine in metastatic renal cell carcinoma [19]. Whether histamine may add efficacy to higher doses of IL-2 and IFN is not clear. The toxicity of this moderate-dose IL-2 and IFN regimen was mainly constitutional symptoms of lethargy and gastrointestinal side-effects of nausea, vomiting and diarrhoea. Histamine did not increase toxicity except for the flushing and metallic taste and the regimen was well tolerated in an outpatient setting.

The present investigation was performed as a phase II study and comparison was made with a non-randomised control group. The control group was treated consecutively before and after the study trial based on exactly the same criteria but without histamine. Patient characteristics and distribution of prognostic factors were comparable in the two groups (Table 3). Nevertheless, one should be very cautious in comparing these two non-randomised groups. Thus, results from the control group can primarily be used to support the conclusion based on the phase II trial by itself. The response rate was comparably low in the two groups (Table 2). The median survival in the study group was 7.8 months and not different from that of the control group of 7.1 months (P = 0.51) (Figure 1). The recently published phase III trial by Agarwala et al. [20] using IL-2 versus IL-2 and histamine included 305 patients and resulted in a comparable response rate of 4%. This study used an IL-2 dosing schedule with 9 MU/m2 on days 1 and 2 in weeks 1 and 3, and 2 MU/m2 on days 1–5 in weeks 2 and 4 for a total of 112 MU/m2 per cycle. In our study, we administered a slightly higher total IL-2 dose of 270 MU per cycle. The dosage of histamine (1 mg b.i.d. on day 1–5) in each treatment week was similar in the two studies and was administered together with IL-2 or IFN-{alpha}. With regard to the histamine and IL-2 the two regimens should be comparable. The study by Agarwala et al. showed no difference in response and overall survival between the study and control group, except for the subgroup of patients with liver metastases where a survival benefit was indicated. In our patients, we found no difference (P = 0.62) in survival of patients with liver metastases between the two groups (data not shown). Similarly, the fact that only one partial response out of 11 patients with liver metastases was observed did not support a beneficial effect of the co-administration of histamine in patients with liver metastases. However, the number of patients with liver metastasis was too small for a valid conclusion concerning this aspect.



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Figure 1. Survival of patients in the study group [interleukin-2 (IL-2), interferon (IFN), histamine; n = 41, two patients alive] versus the non-randomised control group (IL-2, IFN; n = 42, three patients alive)

 
In summary, this regimen was well tolerated on an outpatient basis. However, the applied regimen cannot be recommended because of the low clinical efficacy. There was no indication that histamine did add efficacy or toxicity in combination with this moderate-dose schedule of IL-2 and IFN.


    Acknowledgements
 
Supported by grants from Maxim Pharmaceuticals Inc., San Diego, CA, USA, Chiron Therapeutics, The Netherlands and Schering-Plough Corporation, Denmark.


    Footnotes
 
+ Correspondance to: Dr H. Schmidt, Department of Oncology, Aarhus University Hospital, Norrebrogade 44, DK-8000 Aarhus C, Denmark. Tel: +45-8949-2652; Fax: +45-8619-7109; E-mail: hs{at}oncology.dk Back


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
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