Intralesional 5-Fluorouracil (5FU), Topical Imiquimod Treatment for SCC

Phase I, Dual Arm, Open-Label, Trial of Intralesional 5-Fluorouracil (5FU) and Intralesional 5FU Combined With Topical Imiquimod in Patients With Squamous Cell Carcinoma (SCC) of the Lower Extremities

This clinical trial proposes to evaluate a relatively unexplored approach to treatment of squamous cell carcinoma (SCC) on the lower extremities. The strategy is to directly and specifically deliver drug to the tumor. For the proposed phase I clinical trial, the investigators will perform intralesional injections of a well characterized, potent chemotherapeutic agent 5-fluorouracil (5FU) with and without a topical application of 5% imiquimod to kill topically accessible SCC cells. The goal of the study is to evaluate the safety profile and tolerability of intralesional-5FU with and without a concomitant topical imiquimod and measure the clinical objective response rate (ORR) in treated lesions compared to untreated lesions 3 weeks after treatment.

Squamous cell carcinoma (SCC) of the lower extremity is a distinct subset of cutaneous squamous cell carcinomas which tend to occur multiply in elderly women. In contrast, the majority of cutaneous SCCs occur on the head and neck, and in men more than women. Histopathological studies of lower extremity SCCs revealed that they tend to be well differentiated and have low incidence of perineural and lymphovascular invasion. SCCs of the lower extremity are also less prone to metastasis. Surgical excision has been the mainstay in the treatment of SCC, including lower extremity SCC. However, the lower extremity, as a site, is prone poor wound healing and postoperative complications such as infections. Furthermore, a phenomenon called eruptive postoperative SCC can occur, in which cytokines released during wound healing trigger secondary tumor formation in genetically predisposed cells surrounding the original SCC. Given that lower extremity SCCs are less aggressive but more prone to surgical complications when excised, the investigators believe these types of lesions may be good candidates for non-surgical treatment. 5-fluorouracil (5FU) is a chemotherapeutic agent that has been used systemically for various malignancies, but it has also been used topically or intralesionally for a variety of dermatological conditions. But reports of its use in invasive cutaneous SCC, other than in keratoacanthomas, are very limited. The investigators are aware of 3 such reports in the literature. In the largest study to date, 6 weekly intralesional injections of 5FU-epinephrine gel were performed on 23 patients with cutaneous SCC on various body sites, 22 (96%) of whom demonstrated histologically confirmed tumor clearance. This study, however, used a proprietary gel formulation which is not widely available. There are two other case reports of successful treatment of SCC with 6-8 intralesional injections of 5FU at weekly intervals. The three published studies injected 0.6ml to 2.4ml of 5FU, per each weekly session, at concentrations of 30mg/ml to 50mg/ml. Imiquimod is a topical immune response modulator which acts through the toll-like-receptor 7 pathway. It is FDA approved for the treatment actinic keratosis, genital warts, and superficial basal cell carcinomas. It has also been used off-label for the treatment of squamous cell carcinomas in situ and invasive cutaneous squamous cell carcinomas. A review of published studies to date found 50-88% clearance rate for squamous cell carcinomas in situ treated with daily application of topical imiquimod. There is only one study, other than case reports of treating invasive squamous cell carcinomas with topical imiquimod. In that study, 7 out of 12 (71%) invasive squamous cell carcinomas cleared with topical imiquimod 5 days per week for 12 weeks. Common reported adverse reactions are erythema, pruritus, weeping, erosions, crusting at the application site. The aim of the proposed study is to evaluate a relatively unexplored approach to treatment of SCC on the lower extremities. The strategy is to directly and specifically deliver a drug to the tumor through an injection weekly for three weeks. For the proposed phase I clinical trial, the investigators will perform intralesional injections of a well-characterized, potent chemotherapeutic agent (5-fluorouracil) to kill topically accessible SCC cells. Importantly, 5-fluorouracil is currently in clinical use with a well-established safety profile. It is anticipated that intralesional injections of 5-fluorouracil (5FU) will enable direct and specific delivery of chemotherapy to the tumor, thereby reducing the potential for systemic toxicity. Further, intralesional injections of 5FU enable tumoral delivery of locally effective concentrations of 5FU using doses that are orders of magnitude below those used currently for the intravenous (IV) treatment of multiple malignancies. In addition to the 5FU injections, a subset of study participants will also have their lesions treated with a topical application of 5% imiquimod, another well-characterized chemotherapeutic agent with some demonstrated efficacy in treating cutaneous squamous cell carcinomas. The investigators hope that the concomitant use of topical 5% imiquimod will work synergistically with intralesional 5FU. No study published to date has been found on the concomitant use of intralesional 5FU and topical imiquimod. Participants will have at least 1 SCC lesion greater 1cm and less than 2 cm in largest diameter, on their lower extremities. The clinical diagnosis of SCC will be confirmed histologically by a deep shave biopsy of less than half of the lesion. The remainder of the lesion will be used for intralesional injections of 5FU or intralesional 5FU/topical imiquimod according to the following schema: In this study, a total of 30 participants will be randomly assigned into 3 groups. Randomization will be conducted using the University of Pittsburgh Cancer Institute (UPCI) randomizer, which is maintained by the Biostatistics Facility of UPCI (https://randomize.upci.pitt.edu/randomizer/home.seam).10 participants will serve as a control group, and will receive neither 5FU injection nor topical imiquimod. In another 10 participants, intralesional injections of 50mg of 5FU in 1ml aqueous injectable solution will be administered weekly for 3 weeks. In yet another 10 participants, intralesional 5FU will be administered as in the previous group, additionally participants will also receive three-times-weekly topical application of 5% imiquimod to the same lesion. At the end of week two, a 2mm punch biopsy of the lesion will be obtained for mid-point analysis, and will be stored for tissue banking and future study. A week after the last injection (week 4), the lesion will be surgical resected in all participants including the control group, to render the patients disease free. Resection is the current standard of care for these tumors. A part of, or all of, the resected tumor and surrounding skin will be stored for tissue banking and future studies to characterize and compare the tumor microenvironment before, during, and after therapy. All lesions will be photographed and treatment response will be evaluated 4 weeks after the first 5FU injection prior to excision.

10 participants will serve as a control group, and will receive neither 5FU injection nor topical imiquimod. 10 participants will receive one 1ml intralesional injection of 50mg/ml 5FU aqueous injectable solution every week for 3 weeks. 10 participants will receive intralesional 5FU as in the previous group, additionally they will also receive concomitant three-times-weekly topical application of 5% imiquimod to the same lesion. At the end of week two, a 2mm punch biopsy of the lesion will be obtained for mid-point analysis, and will be stored for tissue banking. A week after the last injection (week 4), the lesion will be surgical resected in all participants including the control group, to render the participants disease free. Resection is the current standard of care. A portion of the resected tumor and skin will also be stored for tissue banking, for future study.

Control group will receive neither 5-fluorouracil (5FU) injection nor topical Imiquimod 5% cream. This group will receive standard of care only. Lesion will be surgical resected on day 21 of study.

5-fluorouracil (5FU) Group participants will receive a 1ml intralesional injection of 5FU 50mg/ml aqueous injectable solution. One injection will be administered weekly for 3 weeks. Injections will occur on d0, d7, and d14. Standard of care will be administered on d21 of study and lesion will be surgical resected.

5-fluorouracil (5FU) + Imiquimod 5% cream Group participants will receive intralesional 5FU as in the previous group, additionally participants will also receive three-times-weekly topical application of 5% imiquimod to the same lesion. Standard of care will be administered on d21 of study and lesion will be surgical resected.

Determine number of subjects experiencing Dose Limiting Toxicity (DLT) higher than grade 2, as defined by CTCAE v. 4.0

To assess Dose Limiting Toxicities (DLT) of intralesional-5FU and intralesional 5FU combined with topical imiquimod in subjects after 3 weeks of treatment. Dose Limiting Toxicities (DLT) are defined as: Higher-than grade 2 hematologic or non-hematologic toxicity that is definitely, probably, or possibly related to intralesional 5FU administration and/or topical imiquimod application. The NCI common terminology criteria for adverse events (CTCAE) version 4.0 will be used. Based on the results of the previous studies on treating SCCs with 5FU injection or topical imiquimod, significant toxicities are not expected. Adverse reactions were limited to local site reactions such as treatment site pain, induration, erythema, edema. If a patient has a DLT, doses will be delayed if any Grade >2 toxicities are not resolved to Grade 1 by the time of the next dose.

Measure reduction in tumor burden to assess clinical objective response rate (ORR) in treated lesions. Response will be evaluated using modified Composite Assessment of Index Lesion Severity (CAILS) criteria by bi-dimensional measurement.

Inclusion Criteria: Biopsy-confirmed SCC more than 1.0 cm and less than 2.0 cm in diameter in the lower extremities, defined as the knees and below. Subjects must have an expected survival of greater than or equal to12 months. Subjects must not be on any other investigational device/drug treatment. Subjects must to be willing to adhere to the instructions of the Investigator and his research team and sign an Informed Consent Form prior to entry into the study. Patient is ≥ 18 years of age on day of signing informed consent. Patient must have a performance status of 0 or 1 on the Eastern Cooperative Oncology Group (ECOG) Performance Scale. Female patient of childbearing potential has a negative urine or serum pregnancy test within 7 days prior to receiving the first dose of study medication. If the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required. The serum pregnancy test must be negative for the patient to be eligible. Female patients enrolled in the study, who are not free from menses for > 2 years, post hysterectomy/oophorectomy, or surgically sterilized, must be willing to use either 2 adequate barrier methods or a barrier method plus a hormonal method of contraception to prevent pregnancy, or to abstain from heterosexual activity throughout the study, starting with the first dose of study drug at visit 1 through 120 days after the last dose of study drug. Approved contraceptive methods include for example: intra-uterine device, diaphragm with spermicide, cervical cap with spermicide, male condoms, or female condom with spermicide. Spermicides alone are not an acceptable method of contraception. Male patients must agree to use an adequate method of contraception starting with the first dose of study drug through 120 days after the last dose of study drug. Exclusion Criteria: Patients with any evidence of nodal (Nx) and/or metastatic disease including distant subcutaneous and/or lymph node metastases. Patients with primary non-cutaneous SCC - such as nasopharyngeal SCC. Patient with history of receiving organ transplantation. Patients with history of iatrogenic systemic immunosuppression. Patients with a history of skin or other disorder(s),that in the opinion of the investigator, requires topical application of steroids and/or other creams/ointments. Patients with evidence of active infection - active and/or untreated hepatitis B/C, HIV, etc - requiring systemic therapy. Patients with a known history of autoimmune disease. Patients with the following cardiac co-morbidities including: Baseline known prolongation of QT/QTc interval (QTc interval >500 msec). Heart failure either on clinical examination (manifestations include ascites, cardiomegaly, dyspnea, edema, gallop rhythm, hepatomegaly, oliguria, pleural effusion, pulmonary edema, tachycardia) or based on known decreased left ventricular ejection fraction (LV EF) <50%. Patients who have had chemotherapy, radioactive or biological cancer therapy within four weeks prior to the first dose of study drug, or who has not recovered to Common Terminology Criteria for Adverse Events (CTCAE) Grade 1 or better from the adverse effects (AEs) due to cancer therapeutics administered more than four weeks earlier. Subjects with ≤ grade 2 neuropathy are an exception to this criterion and may qualify for the study. If patient received major surgery, they must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy. Patients currently participating or who have participated in a study of an investigational agent or using an investigational device within 4 weeks of the first dose of study drug. Patients expected to require any other form of systemic or localized antineoplastic therapy while on study. Patients with a known history of a hematologic malignancy, primary brain tumor or sarcoma, or of another primary solid tumor, unless the patient has undergone potentially curative therapy with no evidence of that disease for five years. ° The time requirement also does not apply to patients who underwent successful definitive resection of basal or squamous cell carcinoma of the skin, superficial bladder cancer, in situ cancers including cervical cancer, breast cancer, melanoma, or other in situ cancers. Patients who have previously had a severe hypersensitivity reaction to 5-fluorouracil or imiquimod. Serious illnesses, such as: cardiovascular disease (uncontrolled congestive heart failure, hypertension, cardiac ischemia, myocardial infarction, and severe cardiac arrhythmia), bleeding disorders, autoimmune diseases, severe obstructive or restrictive pulmonary diseases, active systemic infections, and inflammatory bowel disorders. Patients with a history or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the study, interfere with the patient's participation for the full duration of the study, or are not in the best interest of the patient to participate, in the opinion of the treating Investigator. Patients who are, at the time of signing informed consent, regularly using illicit drugs or are recently (within the last year) abusing illicit substances (including alcohol). Patient is pregnant or breastfeeding, or expecting to conceive or father children within the projected duration of the study.

Individual participant data that underlie the results reported in this article, after deidentification (text, tables, figures, and appendices)

Investigators whose proposed use of the data has been approved by an independent review committee (learned intermediary) identified for this purpose. To achieve aims in the approved proposal. Proposals may be submitted up to 36 months following article publication. Proposals should be directed to puglianomauroma@upmc.edu. To gain access, data requestors will need to sign a data access agreement. Data are available for 5 years through RedCap.

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