A Phase IV Study Of The Impact Of Vorinostat On Cellular Signaling And Cytokine Production In Cutaneous T-Cell Lymphoma Patients With Pruritus
Mycosis Fungoides (MF) is a rare malignancy in the United States. It is the most common form
of cutaneous T-cell lymphoma (CTCL). Sézary syndrome (SS) is the most severe and leukemic
form of CTCL. Severe pruritus is a manifestation of the SS and also affects patients with
MF. Severe pruritus is a manifestation of SS and also a common symptom among patients with
MF. Pruritus can significantly impact on quality of life. In one national survey of the
impact of MF on patients' health-related quality of life (HRQOL), the majority of survey
respondents (88%) reported being bothered by pruritus.
The pathogenesis of pruritus is complex and not well understood. It affects a majority of
patients with mycosis fungoides (MF) and is most severe in Sézary syndrome (SS), the
leukemic form of cutaneous T-cell lymphoma. Chemical or physical stimuli that perturb,
without damaging, only the epidermis (the outer most layer of the skin), elicit the symptom
of pruritus. The perception of itch is abolished if the epidermis is removed. This
observation and the data on PAR2 expression on nerve fibers indicate that pruritus in
inflammatory skin disorders including MF/SS is likely to have a neuroepidermal origin or be
mediated by molecules that percolate to the epidermis from inflammatory cells in the dermis.
In this regard, MF/SS are characterized histologically by infiltration of the epidermis by
neoplastic T cells (epidermotropism), and in some of these cases, the neoplastic cells form
collections of 2-3 cells around epidermal Langerhans cells (Pautrier microabscess).
Neoplastic cells of advanced MF/SS typically are polarized to secrete TH2 cytokines. It has
been hypothesized that the accumulation of neoplastic cells in skin lesions promotes a shift
from a TH1 predominant cytokine profile in early MF to a TH2 predominant cytokine profile in
advanced disease 4. The shift to TH2 production coincides with impaired immune responses,
eosinophilia, and high levels of IgE in the blood. Severe pruritus is more frequent in
patients with advanced MF/SS suggesting that tumor burden or cytokines elaborated by
activated tumor cells may be correlated to intensity of pruritus.
While it is not clear which cells contributed to the TH2 cytokine shift, studies of T-cells
isolated from skin and blood of affected patients showed activation of the signaling
molecule, STAT3. In CTCL lines, constitutively activated STAT3 mediates IL-5 production
(principal regulator of eosinophilia) and IL-13 (favors antibody responses) 5. Moreover,
IL-31 also seems to signal through STAT3 in one lung model. Current treatments of pruritus
are aimed towards symptomatic relief although these do not address the mechanism of
pruritus. If neoplastic cells are producing IL-31 or other pruritogenic factor as we
propose, then any treatment that eliminates these cells will also be effective for pruritus.
To date, effectively improving pruritus and the disease manifestations is not always
possible especially in advanced MF or SS.
Vorinostat is a FDA approved histone deacetylase inhibitor for the treatment of the
cutaneous manifestations of patients with cutaneous T-cell lymphoma (MF/SS) who have
progressive, persistent, or recurrent disease on or following 2 systemic therapies.
Vorinostat induces differentiation, growth arrest, and/or apoptosis of malignant cells both
in vitro and in vivo and has shown clinical responses in approximately 30% of patients with
advanced MF/SS 7. Overall, 32% of patients with severe pruritus had relief of this symptom,
and it was observed that the relief of pruritus often presaged the clinical response,
especially in SS. This suggests to us that the gene modulating effects of vorinostat might
be directly inhibiting expression of IL-31 or other cytokines that mediate pruritus in
MF/SS. IL-31 appears to be implicated in pruritus of atopic dermatitis. 8 Recently, studies
have demonstrated that itch can be mediated by a novel cysteine protease and that
proteinase-activated receptor-2 plays an important role in itch signaling pathways. 9, 10 In
another recent study, substance P has been implicated in itch pathophysiology. In one small
case series of patients with CTCL, the efficacy of aprepitant was evaluated11. Aprepitant is
a substance P antagonist that blocks the neurokinin 1 (NK1) receptor. Substance P has a role
in the physiology of unmyelinated C-fibers in the skin that convey both pain and pruritus
and has the ability to modulate mast cell functioning.
Data from skin biopsies have shown that successful treatment with vorinostat is associated
with decreased dermal and epidermal lymphocytes, a shift from nuclear to cytoplasmic
p-STAT-3 staining, and decreased CD31-positive dermal vessels. This was not confirmed in
another study. Vorinostat has been postulated to indirectly inactivate STAT proteins that
drive cellular proliferation and TH2 cytokine expression. Researchers observed that in skin
biopsies of patients enrolled in the vorinostat stage IIB trial, nuclear accumulation of
STAT1 and high levels of nuclear pSTAT3 in malignant T cells correlated with a lack of
clinical response. To date, there has been no evaluation of STAT3 proteins and TH2 cytokines
in pruritic versus non-pruritic skin lesions of CTCL. Signal transducers and activators of
transcription (STATS) are important to active transcription of cellular proteins including
cytokines. Constitutive activation of STATs has been shown to be a feature of MF/SS.
Since pruritus is a common manifestation of the disease that significantly impacts on
patient's quality of life and that oral vorinostat provides clinical relief from pruritus in
treated patients, understanding the mechanisms of action of vorinostat on cytokines
implicated in pruritus will shed light on its therapeutic effect. In particular, because we
believe that a reduction in pSTAT3 activity as evidenced by fewer and/or less strongly
stained tumor cells may be taking place in patients responding to therapy and reporting
decrease pruritus. Thus, understanding the extent of STAT3 protein aberration and cytokine
expression (IL-31) in pruritic skin lesions could significantly contribute to our
understanding of the mechanism of pruritus in MF/SS and to how vorinostat relieves this
Objectives/Hypothesis It is hypothesized that skin tissue expression of pSTAT3, IL-31, and
cathepsin S will correlate with response to vorinostat, a recently FDA approved therapy for
MF and SS, decreasing in expression with relief of pruritus.
Methods: Dosing and Frequency of Drug
Participants who are cared for at Boston Medical Center will first be assessed by physicians
of the CTCL multi-specialty clinic if vorinostat, administered per standard of care, is an
appropriate therapy for their CTCL. The decision to invite patients to participate in this
study is (1) separate from the above described clinical decision to utilize vorinostat, and
(2) will be offered subsequent to the clinical decision to utilize vorinostat. There is no
placebo group for this study. Up to ten participants are desired for this study.
Three biopsies will be taken: (1) at baseline; (2) after 4 weeks of 300 mg daily vorinostat,
and (3) if tolerated, after 4 more weeks of 400 mg daily vorinostat. At each time point, up
to 2 biopsies will be taken depending on if 1 or both skin types are present (itchy vs
non-itchy) at that time point and whether or not itchy or non-itchy skin shows a lesion.
For each time point and each skin type, pSTAT3 staining will be measured as strong (2+),
weak (1+), none (0). At each time point, patients will report the extent of their pruritus
on a visual analogue score (VAS) from 0-100 mm (0, no pruritus; 100, worst imaginable
pruritus). Meaningful change in pruritus will be a change in VAS score of 30 mm or more
from baseline to the third time point (a change measure that will also be computed for all
endpoints; the baseline to time 3 measure being of primary clinical interest).
Sample Size/Accrual Rate: The total enrollment planned is 10 patients at a rate of 1-2
patients per month. With 10 subjects, for our primary hypothesis (correlation of staining
intensity with self-reported degree of pruritis) we can detect a Spearman rank correlation
coefficient as small as 0.75 for a one-sided test with 80% power (a directional hypothesis
that is reasonable) or one as small as 0.80 for a two-sided hypothesis. In each case, these
coefficients are of clear clinical relevance and are plausible given the nature of the
measures. For the hypothesis of equal changes between treated and control areas on the same
individuals, we propose using paired data analyses such as paired t-tests and Wilcoxon rank
sum tests. For a sample size of 10 and 80% power, a paired t-test can detect an effect size
of 0.996 or greater for a two-sided test and an effect size of 0.853 or greater for a
one-sided test. These effect sizes are large but are within reason to expect for a
clinically effective treatment.
Observational Model: Cohort, Time Perspective: Prospective
the percentage change in pSTAT3 expression among patients reporting a relief in their pruritus, irrespective of lesion clearing
For each time point and each skin type, pSTAT3 staining will be measured as strong (2+), weak (1+), none (0). At each time point, patients will report pruritus on a visual analogue score (VAS) from 0-100 mm (0, none; 100, worst imaginable). Meaningful change in pruritus is a change in VAS score of 30 mm or more from baseline to the third time point (a change measure that will also be computed for all endpoints; the baseline to time 3 measure being of primary clinical interest). Spearman rank correlation will examine the significance of the association between the change in cytoplasmic staining intensity and change in pruritus as assessed by subjects with the visual analog scale, neither of which will be assumed to follow a Gaussian distribution. For descriptive purposes only, analyses will also be performed stratified on pruritis stage at baseline (early stage I-IIA vs. late stage IIB-IVB and pruritus, mild VAS less than 40 vs. moderate to severe VAS greater than 40, up to 100).
Deon Wolpowitz, MD, PhD
United States: Food and Drug Administration
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