Impact of Vorinostat on Pruritus Signaling Pathways - Merck Study

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.

Study Rationale:

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
serious symptom.

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.

Inclusion Criteria:

- Patients w/ histologically confirmed mycosis fungoides stage IB to IVA eligible to
receive oral vorinostat

- Patients w/ stage IB to IV reporting pruritus

- Patients age 18-85 years, of any race, sex, and ethnicity

- Life expectancy > 24 weeks

- Patient must have performance status of ≤2 on the ECOG Performance Scale

- Patients w/ a min. of 3 weeks since their last systemic treatment

- Women who are not pregnant, lactating, or of childbearing potential

- Female patients w/ reproductive potential must use an adequate contraceptive method
during treatment and for three months after completing treatment

- Male patient w/ reproductive potential, agrees to use an adequate method of
contraception for the duration of the study and for 30 days beyond the duration of
study

- Patients, or legal representative must to be willing to adhere to the protocol, and
sign an Informed Patient Consent Form prior to entry into the study

- Patients must not be on any other investigational device/drug treatment for MF/SS

- Patient is available for periodic blood sampling, study related assessments, and
management at the treating institution for the duration of the study

- Eligibility of patients receiving medications or substances known or with the
potential to affect the activity or pharmacokinetics of vorinostat will be determined
by the Principal Investigator

- Patient must have adequate organ function as indicated by laboratory values

Exclusion Criteria:

- Patients w/ a recent cardiac history, such as a myocardial infarct within the last
year, uncontrolled angina, severe uncontrolled ventricular arrhythmias, clinically
significant pericardial disease, or electrocardiographic evidence of acute ischemic
or active conduction system abnormalities

- Patients w/ a history of liver damage (2.5 x normal ALT, AST), leukopenia, or
thrombocytopenia

- Women who are pregnant or nursing a child

- Patients w/ severe emotional, behavioral or psychiatric problems that, in the opinion
of the investigator, would result in poor compliance with the treatment regimen

- Patients who have received and histone deacetylase inhibitor within the last 6 months

- Patients receiving valproic acid will be excluded unless there has been a wash-out
period of 30 or more days

- Patients who will have received systemic therapy, radiation therapy or phototherapy
within 3 weeks prior to initial dosing with study drugs or who has not recovered
from adverse events due to agents administered more than 3 weeks earlier

- QTc prolongation greater than 500ms

- Patient w/ a "currently active" second malignancy, other than non-melanoma skin
cancer and carcinoma in situ of the cervix, should not be enrolled

- Patients are not considered to have a "currently active" malignancy if they have
completed therapy for a prior malignancy, are disease free from prior malignancies
for >5 years or are considered by their physician to be at less than 30% risk of
relapse

- Patient is on any systemic steroids that have not been stabilized during the 3 weeks
prior to the start of the study drugs

- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to vorinostat

- Patient has known psychiatric or substance abuse disorders that would interfere with
cooperation with the requirements of the trial

- Patient is, at the time of signing informed consent, a regular user of any illicit
drugs, substance abuse or had a recent history (within last year) of drug or alcohol
abuse

- Patient has uncontrolled intercurrent illness or circumstances that could limit
compliance with the study, including, but not limited to: active infection, acute or
chronic graft versus host disease, symptomatic congestive heart failure, unstable
angina pectoris, cardiac arrhythmia, or psychiatric conditions

- Patient has a history or current evidence of any condition, therapy, or lab
abnormality that might confound the results of the study, interfere with the
patient's participation for the full duration of the study or is not in the best
interest of the patient to participate

- HIV-positive patients will be ineligible

- Patients w/ known history of Hepatitis B or C are excluded