First-In-Class CD13-Targeted Tissue Factor tTF-NGR in Patients with Recurrent or Refractory Malignant Tumors: Results of a Phase I Dose-Escalation Study

Christoph Schliemann, Mirjam Gerwing, Hauke Heinzow, Saliha Harrach, Christian Schwöppe, Moritz Wildgruber, Anna A Hansmeier, Linus Angenendt, Andrew F Berdel, Ursula Stalmann, Björna Berning, Karsten Kratz-Albers, Kristina Middelberg-Bisping, Stefanie Wiebe, Jörn Albring, Christian Wilms, Wolfgang Hartmann, Eva Wardelmann, Tobias Krähling, Walter Heindel, Joachim Gerss, Eike Bormann, Hartmut Schmidt, Georg Lenz, Torsten Kessler, Rolf M Mesters, Wolfgang E Berdel, Christoph Schliemann, Mirjam Gerwing, Hauke Heinzow, Saliha Harrach, Christian Schwöppe, Moritz Wildgruber, Anna A Hansmeier, Linus Angenendt, Andrew F Berdel, Ursula Stalmann, Björna Berning, Karsten Kratz-Albers, Kristina Middelberg-Bisping, Stefanie Wiebe, Jörn Albring, Christian Wilms, Wolfgang Hartmann, Eva Wardelmann, Tobias Krähling, Walter Heindel, Joachim Gerss, Eike Bormann, Hartmut Schmidt, Georg Lenz, Torsten Kessler, Rolf M Mesters, Wolfgang E Berdel

Abstract

Background: Aminopeptidase N (CD13) is present on tumor vasculature cells and some tumor cells. Truncated tissue factor (tTF) with a C-terminal NGR-peptide (tTF-NGR) binds to CD13 and causes tumor vascular thrombosis with infarction.

Methods: We treated 17 patients with advanced cancer beyond standard therapies in a phase I study with tTF-NGR (1-h infusion, central venous access, 5 consecutive days, and rest periods of 2 weeks). The study allowed intraindividual dose escalations between cycles and established Maximum Tolerated Dose (MTD) and Dose-Limiting Toxicity (DLT) by verification cohorts.

Results: MTD was 3 mg/m2 tTF-NGR/day × 5, q day 22. DLT was an isolated and reversible elevation of high sensitivity (hs) Troponin T hs without clinical sequelae. Three thromboembolic events (grade 2), tTF-NGR-related besides other relevant risk factors, were reversible upon anticoagulation. Imaging by contrast-enhanced ultrasound (CEUS) and dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) showed major tumor-specific reduction of blood flow in all measurable lesions as proof of principle for the mode of action of tTF-NGR. There were no responses as defined by Response Evaluation Criteria in Solid Tumors (RECIST), although some lesions showed intratumoral hemorrhage and necrosis after tTF-NGR application. Pharmacokinetic analysis showed a t1/2(terminal) of 8 to 9 h without accumulation in daily administrations.

Conclusion: tTF-NGR is safely applicable with this regimen. Imaging showed selective reduction of tumor blood flow and intratumoral hemorrhage and necrosis.

Keywords: CD13; aminopeptidase N; first-in-class phase I study; tTF-NGR; vascular targeting.

Conflict of interest statement

W.E.B. and R.M. share a patent on vascular targeting with tissue factor-constructs. W.E.B. and C.S. (Christian Schwöppe) founded a biotech company named ANTUREC Pharmaceuticals GmbH, which will be involved in the future development of tTF-NGR. The other authors declared no competing financial interests.

Figures

Figure 1
Figure 1
Distribution of all patients treated and cycles of tTF-NGR given over the dose range studied. UPN, unique patient number; for further information, see Table 1; C, cycle; EOT, end of treatment; DLT, dose limiting toxicity; VG, verification group.
Figure 2
Figure 2
Contrast-enhanced ultrasound (CEUS) measurement (UPN 006) of wash-in perfusion index (WIAUC/RT, see Supplementary Figure S1) in liver metastasis (green and purple) versus normal liver (yellow) reference region of interest (ROI) before (upper panel, (A)) versus after 5 days of treatment with 2.5 mg/m2 tTF-NGR per day (lower panel, (B)).
Figure 3
Figure 3
Heat maps of dynamic CEUS in a liver metastasis lesion of a colon adenocarcinoma (UPN 023) before and after 3 days of tTF-NGR (cycle 1). Left part: Before treatment with tTF-NGR at 3.0 mg/m2. Right part: Decrease of contrast perfusion after 3 days of 3 mg/m2 tTF-NGR. Color scales at the right lower corner of each photograph semiquantify contrast perfusion (red = high, blue/black = low). The green circle represents “total lesion”, and the yellow circle represents the “central lesion” (for values, see Supplementary Table S4).
Figure 4
Figure 4
Early evaluation of activity of tTF-NGR using Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI): Transverse images show the liver in a 22-year-old patient (UPN 003) with metastatic non-seminomatous germ cell tumor as treated in cycle 1 (1 mg/m2 tTF-NGR per day). Images of tumor (T) before (a–c) and after five days of therapy (d–f): Comparisons of tumor diameter before treatment (dotted line (a)) versus after treatment (dotted line (d)) reveal a moderate increase in tumor diameter 5 days after the beginning of treatment. Comparisons of tumor perfusion maps (volume transfer coefficient k-trans) demonstrate a notable reduction in tumor perfusion (b,e). Modelled perfusion parameter (k-trans) from before treatment (c) and after treatment (f) show a reduction in calculated k-trans values of >50% and delayed enhancement kinetics, indicating a substantial reduction in tumor perfusion. In contrast, healthy liver tissue (L in Figure 4a) shows a moderately enhanced perfusion after therapy. The line diagram (g) visualizes a first reduction of tumor perfusion already 5 h after treatment initiation (immediate) compared to the baseline scan (pre), with further decrease after five days of therapy (post).
Figure 5
Figure 5
Early evaluation of tumor perfusion response to tTF-NGR using R2* mapping in MRI: R2* maps before (a) and after (b) injection of the iron-based contrast medium Resovist® visualize the perfusion of 3 liver metastases (R = right, C = central, and L = left) of a patient with a colorectal carcinoma (UPN 007). The calculated vascular volume fractions (VVF) demonstrate a reduction in blood flow after treatment with tTF-NGR for each of the 3 cycles (c) at 3 (cycle 1), 4 (cycle 2), and 5 (cycle 3) mg/m2 tTF-NGR per day × 5. Notice the partial reperfusion at the beginning of cycles 2 and 3. (c) y-axis shows arbitrary units, black circles represent measurements before (pre) treatment with tTF-NGR, black squares are 5 h (immediate) after tTF-NGR, and black triangles are after 5 days (post) of tTF-NGR at the end of a cycle.
Figure 6
Figure 6
Morphological changes in hepatocellular carcinoma (HCC) (UPN 022) under tTF-NGR therapy: In the initial MRI scans, two prominent HCC lesions are visible in a transversal T2 weighted image. Before treatment with tTF-NGR, the HCC lesions are homogenously hyperintense as compared to the surrounding liver tissue (upper panels). After two cycles with tTF-NGR at 3.0 mg/m2 × 5, morphological changes with multiple hemorrhagic regions (*) have occurred inside the tumor lesions (lower panels), and at the same time, enlargement of tumor diameters can be seen.
Figure 7
Figure 7
Pharmacokinetics with plasma concentration—time curves of tTF-NGR for different doses applied: (A) Cmax values at the end of infusion (1 h) and dose-time curves when 1–4 mg/m2 tTF-NGR were given over 1 h on day 1 (0–24 h). Interpretation of pharmacokinetic (PK) values at 5 mg/m2 dose level (see Supplementary Table S7) was complicated by difficulties to draw and prepare blood samples for testing due to sticky consistency. (B) Values of all patients in the verification cohort at 3 mg/m2 tTF-NGR at day 1, at each of the following 4 days of tTF-NGR application (peak at the end of infusion and trough before the next application), and for cycle 1 (red) and cycle 2 (blue).

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