Trial Information

Safety, Immunology, and Biological Activity Evaluation of TroVax® in Treatment of Patients With Locally Advanced or Metastatic Renal Carcinoma

Objectives

Primary:

- To assess the safety and tolerability of TroVax® injections when given as first or
second line treatment in conjunction with subcutaneous low dose IL-2 to patients with
locally advanced or metastatic clear cell or papillary cell renal carcinoma.

- To assess the immune responses induced by treatment with TroVax® and subcutaneous low
dose IL-2.

Secondary:

- To assess tumour response rates, time to progression, survival and progression free
survival at 6, 12 and 24 months after commencement of treatment with subcutaneous low
dose IL-2.

- To assess the ability of the reintroduction of low dose subcutaneous IL-2 to induce
further disease responses or stabilisation in patients being treated with TroVax®
alone.

Study design:

This will be an open label evaluation in patients with clear cell or papillary cell renal
carcinoma requiring immunotherapy for locally advanced or metastatic disease. A single dose
level of TroVax® in combination with a clinically accepted regimen of subcutaneous low dose
IL-2 will be tested in 25 evaluable patients and their immunological responses to TroVax®
(antibody and cellular) will be assessed. If immunological activity is observed after two
cycles of TroVax®/IL-2 in 70% or more of these patients, further randomised trials will be
undertaken to determine the clinical efficacy of TroVax® in this group of patients.

The dosage schedule of subcutaneous low dose IL-2 will be an initial dose schedule of
250,000 U/kg/dose for 5 days in week 1 followed by 125,000 U/kg/dose for 5 days in each of
weeks 2 though 6 inclusive. There will then be a two-week recovery period before the next
cycle commences. The dosage regimen of TroVax® will be injections given prior to the first
cycle on two occasions (weeks -2 and 1), and one injection given at the beginning of week 4
of the first cycle. In subsequent cycles, booster injections of TroVax® will be given at
week 1 only, prior to commencement of subcutaneous IL-2 therapy. After the first and second
cycles of combined treatment, patients will be evaluated by CT scan for their response to
treatment. If their disease has progressed after the second cycle, they will be withdrawn
from the trial if they require alternative therapy (deterioration of one level of the
Karnofsky score or appearance of disease in a new site). If they are experiencing
progressive disease that does not require alternative therapy or stable disease or better,
they will be treated with cycles of TroVax®/IL-2 as described above for up to a further four
cycles. The tumour status will be evaluated by CT scan after every cycle.

All patients will be monitored for up to 6 cycles (48 weeks) to assess tolerability,
induction of humoural and cellular immunity to 5T4 cell surface antigen, immune response to
the vector, tumour response rates, survival, time to progression and progression free
survival. Patients who are intolerant of further treatments with subcutaneous IL-2 during
this part of the study will be withdrawn from the study.

Patients who are still stable or experiencing a tumour response at 48 weeks will be offered
further boosts with TroVax® without IL-2 every three months at weeks 52, 64, 76, 88 and 100.
During this period, if disease progression recurs, two further cycles with subcutaneous IL-2
as described above may be given in combination with TroVax® as described above with the
objective of inducing further disease response or stabilisation.

Following termination of all patients' participation in the trial (including those with
progressive disease after two cycles of TroVax®/IL-2), contact will be kept by the
Investigators with their families in order to determine the date of death.

A total of 25 patients will be enrolled.

Study population:

Inclusion criteria

1. Locally advanced or metastatic, histologically proven clear cell or papillary cell
renal carcinoma.

2. Primary tumour surgically removed.

3. Progressive disease.

4. At least four weeks from any previous therapy for renal cancer.

5. Fit for first or second line immunotherapy with subcutaneous low dose IL-2.

6. Measurable disease.

7. Aged 18 years or more.

8. Patients must comply with the following:

- Karnofsky score ≥ 80%.

- Corrected calcium ≥ 10 g/dL (2.5 mmols/L).

9. Clinically immunocompetent.

10. Free of clinically apparent autoimmune disease.

11. Haemoglobin ≥ 9 g/dL, total white cell count ≥ 3 x 10^9/L and lymphocyte count ≥ 1 x
10^9/dL.

12. Serum creatinine up to 1.5 times upper limit of normal.

13. Bilirubin ≤ 2 mg% and an SGPT of ≤ 4 times the upper limit of normal.

14. Able to give written informed consent and to comply with the protocol.

15. Women must be either post menopausal, or rendered surgically sterile or, if of child
bearing potential, must have been practising a reliable form of contraception (oral
contraception + a barrier method) for at least three months prior to the first dose of
TroVax® and must continue while they are being treated with TroVax®. Men must practise
a reliable form of contraception while they are being treated with TroVax®.

16. No acute changes on 12-lead ECG.

17. Ejection fraction on echocardiogram ≥ 45%

Exclusion criteria

1. Previous immunotherapy with any schedule of IL-2.

2. Intercurrent serious infections within the 28 days prior to entry into the trial.

3. Life threatening illness unrelated to cancer.

4. Cerebral metastases on MRI scan.

5. History of allergic response to previous vaccinia vaccinations.

6. Participation in any other clinical trial of a licensed or unlicensed drug within the
previous 30 days or during the course of this trial.

7. Previous malignancies within the last 10 years other than successfully treated squamous
carcinoma of the skin or in situ carcinoma of the cervix treated with cone biopsy.

8. Previous history of major psychiatric disorder requiring hospitalisation or any current
psychiatric disorder that would impede the patient's ability to provide informed
consent or to comply with the protocol.

9. Known allergy to egg proteins.

10. Chronic oral corticosteroid use unless prescribed as replacement therapy in the case of
adrenal insufficiency.

11. Known to test positive for HIV or hepatitis B or C.

12. Known hypersensitivity to neomycin.

13. Pregnancy or lactation.

Withdrawal criteria from the trial:

1. Non-compliance with the protocol.

2. Patient withdraws consent.

3. Progressive disease with new sites of disease demonstrated on CT scan and/or requiring
other cancer treatment (deterioration in Karnofsky performance score of 10% or more).

4. Death.

5. Serious IL-2 related adverse events or lack of tolerance to further treatment with IL-2

6. Serious TroVax® related adverse events (DLT).

Treatment plan and methods:

Patients complying with the entry criteria will be invited to enter the study. After
giving fully informed consent, patients will be subjected to a physical examination to
document general fitness to proceed with the trial. Vital signs will be recorded.
Performance status (Karnofsky) will be documented. At that time, metastases will be
documented using chest, abdominal and pelvic CT scans and an MRI scan of the brain will
be obtained. Blood samples will also be obtained for clinical pathology (10 mL; safety
testing). A urine sample will be tested for protein and blood (safety testing). A 12
lead ECG and echocardiogram will be obtained. This screen should not occur more than
two weeks before treatment with TroVax® begins. If available, tumour tissue from
earlier biopsies will be obtained and tested for the presence of tumour antigens, e.g.
5T4. CT scans must be compared with scans obtained within the previous three months in
order to determine that the disease is progressing.

Week -2, day 1:

Obtain blood sample for HLA testing and immunological evaluation, (antibody and T-cell
responses to the vector and the 5T4 surface antigen; 100 mL).

Safety testing (blood, 10 mL and urine)

TroVax® injection i.m. 1 mL

Cycle 1, Week 1 day 1:

Karnofsky score

Vital signs

TroVax® injection i.m. 1 mL (time 0)

Vital signs (1 hour)

Vital signs (3 hours)

IL-2 subcutaneous injection (250,000 U/kg/dose)

safety testing

Cycle 1, Week 1, days 2-5:

IL-2 subcutaneous injection (250,000 U/kg/dose)

Cycle 1, Week 2, day 1:

Obtain samples for immunological evaluation (100 mL blood) and safety testing (blood 10
mL and urine)

IL-2 subcutaneous injection (125,000 U/kg/dose).

Week 2, days 2-5:

IL-2 injection subcutaneous (125,000 U/kg/dose).

Week 3, days 1-5:

Safety testing (blood and urine; day 1 only)

IL-2 subcutaneous injection (125,000 U/kg/dose).

Week 4, day 1:

Safety testing

Vital signs

TroVax® injection i.m. 1 mL (time 0)

Vital signs (1 hour)

Vital signs (3 hours)

IL-2 subcutaneous injection (125,000 U/kg/dose).

Week 4, days 2-5:

IL-2 subcutaneous injection (125,000 U/kg/dose).

Week 5, days 1-5:

Obtain sample for immunological evaluation (blood) and safety testing (blood 10 mL and
urine; day 1 only)

IL-2 subcutaneous injection (125,000 U/kg/dose).

Week 6, days 1-5:

Obtain sample for safety testing (blood 10 mL and urine; day 1 only) IL-2 subcutaneous
injection (125,000 U/kg/dose).

Week 8 day 1:

CT scan for information.

Physician examination.

Safety blood (10 mL) and urine

Cycles 2-6 week 1, day 1:

Obtain sample for safety testing (blood 100 mL and urine)

Vital signs

Karnofsky score

TroVax® injection i.m. 1 mL (time 0)

Vital signs (1 hour)

Vital signs (3 hours)

IL-2 subcutaneous injection (250,000 U/kg/dose)

Cycle 2-6, week 1, days 2-5:

IL-2 subcutaneous injection (250,000 U/kg/dose)

Cycles 2-6, Week 2, day 1:

Obtain sample for immunological evaluation (blood) and safety testing (blood and
urine).

IL-2 subcutaneous injection (125,000 U/kg/dose).

Cycles 2-6, Week 2, days 2-5:

IL-2 subcutaneous injection (125,000 U/kg/dose).

Cycles 2-6, Weeks 3-6, days 1-5:

Safety testing (blood 10 mL and urine day 1 only)

IL-2 subcutaneous injection (125,000 U/kg/dose)

Cycles 2-6, Week 8, day 1:

Obtain blood for safety testing (blood and urine)

CT scan.

Physician examination.

At the end of cycle 2 to 6 inclusive, if disease has progressed and requires other
treatment (deterioration in Karnofsky performance score by 10% or more, disease appears
in a new site), withdraw patient from trial. Also withdraw patient if intolerant of
subcutaneous low dose IL-2 at the lowest permissible dose or if the patient experiences
DLT. Patients withdrawing before they receive the first four doses of TroVax® and give
blood for immunology testing in cycle 2, week 2 will be replaced.

If disease is stable, responding or progressing (but Karnofsky score unchanged, no new
disease sites) and patient is tolerant of treatment, continue with further therapy.

After six cycles of combined study drugs (48 weeks), assess with CT scan at week 48 day
1:

If disease has progressed and requires alternative treatment (deterioration in
Karnofsky performance score by 10% or more or disease appears in a new site), withdraw
patient from trial.

If disease is stable or responding or progressing (but Karnofsky score stable and no
new disease sites) and patient is tolerant of treatment, continue with further therapy.
This therapy will be TroVax® injection every three months, on weeks 52, 64, 76, 88,
100. Perform physician examination on each occasion and assess Karnofsky score prior
to injection. Obtain samples for safety testing (blood 10 mL and urine) and
immunological evaluation (10 mL sample only for antibody testing) prior to each
injection. A further 10 mL sample for immunological evaluation will be obtained one
week after each TroVax® injection. CT scans will be obtained at weeks 63, 75, 87, 99.
At each CT scan, assess:

If disease has progressed, recommence subcutaneous low dose IL-2 treatment (6 weeks on,
two weeks off IL-2) at week 64, 76, 88 as appropriate and give a further 2 cycles of
subcutaneous low dose IL-2.

If IL-2 restarted at week 64 (76, 88), schedule is:

Week 64 (or 76, 88), day 1:

Safety testing (blood 10 mL and urine)

TroVax® injection i.m. 1 mL

Karnofsky score

IL-2 subcutaneous injection (250,000 U/kg/dose)

Physical examination

Week 64 (or 76, 88), days 2-5:

IL-2 subcutaneous injection (250,000 U/kg/dose)

Week 65 (or 77, 89), days 1-5:

Safety testing (blood 10 mL and urine, day 1 only).

Immunological evaluation, 10 mL sample only (day 1 only)

IL-2 subcutaneous injection (125,000 U/kg/dose).

Weeks 66-69 (or 78-81, or 90-93), days 1-5:

Safety testing (blood 10 mL and urine, day 1 only).

IL-2 subcutaneous injection (125,000 U/kg/dose).

Week 71 (or 83 or 95) day 1:

Physician examination.

CT scan.

Second Cycle:

Week 72 (or 84, 96), day 1:

Safety testing (blood 10 mL and urine)

TroVax® injection i.m. 1 mL

Karnofsky score

IL-2 injection (250,000 U/kg/dose)

Week 72 (or 84, 96), days 2-5:

IL-2 injection (250,000 U/kg/dose)

Week 73 (or 85, 97), days 1-5:

Safety testing (blood 10 mL and urine, day 1 only).

Immunological evaluation, 10 mL sample only (day 1 only)

IL-2 subcutaneous injection (125,000 U/kg/dose).

Weeks 74-77 (or 86-89, or 98-101), days 1-5:

Safety testing (blood and urine, day 1 only).

IL-2 subcutaneous injection (125,000 U/kg/dose).

Week 79 (or 91 or 103) day 1:

Physician examination.

CT scan.

After the second cycle of IL-2, if disease has progressed and requires other treatment
(deterioration in Karnofsky score by 10% or more, disease appears in a new site),
withdraw patient from trial.

If the treatment cycles with IL-2 end before week 104 and the patient is responding,
stable or progressing but not in need of alternative therapies (Karnofsky stable, no
new disease sites), recommence TroVax® on the original schedule (see Flow Chart). If
disease is progressing and requires further therapy (deterioration in Karnofsky score
by 10% or more, disease appears in a new site), withdraw patient from trial.

Four weeks after the final treatment, all patients will, if possible, attend for a
final follow up visit. The following will be obtained:

Physical examination.

Karnofsky score

Safety testing (blood 10 mL and urine).

All study visits must occur within +/- 3 days of the day stipulated in the protocol.

If patients withdraw at any time during the trial, a final follow up visit, if
possible, will be obtained four weeks after withdrawal.

Concomitant medication and adverse events will be recorded at each visit.