Pioglitazone for Oral Premalignant Lesions

PRIMARY OBJECTIVES:

I. To determine the clinical and histologic response of oral premalignant lesions to 24
weeks of therapy with pioglitazone, 45 mg once daily (qd), defined as 50% or greater
reduction in the sum of all measured products of perpendicular dimensions of target lesions,
or improvement in the degree of dysplasia or hyperplasia.

SECONDARY OBJECTIVES:

I. To determine the degree of change of putative biomarkers of pioglitazone efficacy
including (but not restricted to) and in order of priority, tissue levels of:

- PPAR gamma,

- cyclin D1 and p21 as indirect measures of pharmacological effect

- TUNEL for apoptosis and Ki-67 for proliferation

- transglutaminase and involucrin as markers of squamous differentiation

- 15-PGDH, loss of heterozygosity (LOH). II. To determine the degree of change of
C-reactive protein (CRP) in plasma. III. To assess tobacco and alcohol use among trial
participants and to examine the relationship of tobacco and alcohol use to treatment
response.

IV. To assess the safety of this agent in this population.

OUTLINE: Patients are randomized to 1 of 2 treatment arms.

ARM I: Patients receive pioglitazone hydrochloride orally (PO) once daily (QD) for 24 weeks.

ARM II: Patients receive placebo PO QD for 24 weeks.

After completion of study treatment, patients are followed up for 2 weeks.

Inclusion Criteria:

- STAGE I:

- Males or females with a suspected or histologically confirmed oral premalignant
lesion(s) (up to three target lesions may be followed for the purpose of the study)
that has a length (longest diameter) of 8 mm or greater and width (diameter
perpendicular to greatest length) of 3 mm or greater in size

- If a participant has had a biopsy of the target oral premalignant lesions (OPL)
lesion(s) within 6 weeks prior to the screening visit and archival tissue is
available and the participant agrees to have archival tissue used for histologic
confirmation and biomarker analysis, then NO additional biopsies (of the OPL)
need to be performed at the screening visit; the pre-screening biopsy must
undergo centralized pathology review before the second stage of registration can
be performed; if archival tissue is not available, a waiting period of 6 weeks
from the time of the last biopsy must be observed before re-biopsy for study
purposes

- If a participant has not had a biopsy of the suspected OPL at the time of the
screening visit, then a biopsy of the lesion must be performed during the
screening visit; the screening biopsy must undergo centralized pathology review
before the second stage of registration can be performed

- The participant's life expectancy is > 6 months

- The participant has discontinued any other oral cancer chemopreventive therapy at
least 12 weeks prior to the baseline visit and all toxicities have been fully
resolved; daily aspirin is permitted

- The participant is willing and able to fully participate for the duration of the
study

- Women must not be pregnant or lactating; women of child-bearing potential (women are
considered not of childbearing potential if they are at least two years
postmenopausal and/or surgically sterile) must have used adequate contraception
(abstinence; barrier methods such as IUD, diaphragm with spermicidal gel, condom, or
others; and hormonal methods such as birth control pills or others) since her last
menses prior to study entry; women of child-bearing potential and men must agree to
use adequate contraception for the duration of study participation; should a woman
become pregnant or suspect she is pregnant while participating in this study, she
should inform her study physician immediately

- Ability to understand and the willingness to sign a written informed consent document

- STAGE II:

- The participant has one or more target lesions histologically confirmed by a biopsy
obtained no more than 9 weeks prior to randomization, that is either:

- An EARLY premalignant lesion defined to be at high risk:

- Mild dysplasia of any site

- Hyperplastic leukoplakia of a high-risk site

- Dorsal, lateral or ventral tongue

- Floor of mouth

- An ADVANCED premalignant lesion defined as the presence of at least one of the
following:

- Moderate dysplasia

- Severe dysplasia (excluding carcinoma in situ)

- Erythroplakia (due to the high risk for progression associated with
erythroplakia, erythroplakia of any histology will be defined as an
ADVANCED oral premalignant lesion)

- Hemoglobin levels equal to or above the lower limit of normal

- White blood cells >= 3,000/uL

- Platelets >= 125,000/uL

- Total bilirubin =< 1.5 * upper limit of normal (ULN)

- BUN and serum creatinine =< 1.5 * ULN

- Glucose, serum < 200 mg/dL

- The participant's Eastern Cooperative Oncology Group (ECOG) performance status is 0
or 1

- If the participant is female and of childbearing potential and not lactating she has
a documented negative serum pregnancy test within 14 days prior to randomization

- The participant has a baseline EKG that does not show signs of acute cardiac ischemia
or cardiac dysrhythmia (except for 1st degree AV block or chronic atrial
fibrillation); EKG can be an earlier report within 12 weeks prior to registration

- Participants using the drugs listed below may not be randomized unless they are
willing to stop the medications (and possibly change to alternative non-excluded
medications to treat the same conditions) no less than 3 days prior to starting
pioglitazone or placebo on this study; the use of the following drugs or drug classes
is prohibited during pioglitazone/placebo treatment: participants taking inhibitors
of CYP2C8 (gemfibrozil, ketoconazole, quercetin, trimethoprim), enzyme inducers of
CYP2C8 (cortisol, dexamethasone, phenobarbital, rifampin), and CYP3A4 substrate

Exclusion Criteria:

- The participant has active cancer or carcinoma in situ of the head and neck

- The participant has a contraindication to biopsy

- The participant has presence of congestive heart failure (New York Heart Association
(NYHA) class II-IV), uncontrolled hypertension (systolic > 150 or diastolic > 100),
or unstable angina

- The participant has any history of congestive heart failure or history of myocardial
infarction within the past 6 months

- The participant exhibits clinical evidence of active liver disease or history of
chronic liver disease

- The participant has > Common Terminology Criteria for Adverse Events (CTCAE) grade 1
edema

- The participant has known diabetes and is on insulin or oral agents; the participant
is receiving medical therapy for dysregulated blood sugar

- The participant who currently receives an enzyme inhibitor of CYP2C8 (gemfibrozil,
ketoconazole, quercetin, trimethoprim), or enzyme inducer of CYP2C8 (cortisol,
dexamethasone, phenobarbital, rifampin), or CYP3A4 substrate will not be eligible for
randomization after assessing eligibility in stage two unless he/she will not be
eligible for randomization after assessing eligibility in stage two unless he/she is
willing to stop these drugs and possibly replace them with alternative therapies

- The participant currently receives pregabalin or thioridazine

- The participant has experienced jaundice with Rezulin (troglitazone)

- The participant has a history of colorectal cancer, familial adenomatous polyposis
(FAP) or hereditary non-polyposis colorectal cancer (HNPCC)

- The participant has a history of bladder cancer or in situ bladder cancer

- The participant has a history of invasive cancer within the past 18 months (excluding
non-melanoma skin cancer and in situ cervical cancer); participants (excluding those
with a history of colorectal cancer, FAP, HNPCC, bladder cancer or in situ bladder
cancer) who received curative treatment and have shown no evidence of recurrence for
18 months will be eligible