Continuous 24h Intravenous Infusion of Mithramycin, an Inhibitor of Cancer Stem Cell Signaling, in People With Primary Thoracic Malignancies or Carcinomas, Sarcomas or Germ Cell Neoplasms With Pleuropulmonary Metastases

Background:

Increasing evidence indicates that activation of stem cell gene expression is a common
mechanism by which environmental carcinogens mediate initiation and progression of thoracic
malignancies. Similar mechanisms appear to contribute to extra-thoracic malignancies that
metastasize to the chest. Utilization of pharmacologic agents, which target gene regulatory
networks mediating stemness may be novel strategies for treatment of these neoplasms. Recent
studies performed in the Thoracic Epigenetics Laboratory, TGIB/NCI, demonstrate that under
exposure conditions potentially achievable in clinical settings, mithramycin diminishes stem
cell gene expression and markedly inhibits growth of lung and esophageal cancer and malignant
pleural mesothelioma (MPM) cells in vitro and in vivo. These findings add to other recent
preclinical studies demonstrating impressive anti-tumor activity of mithramycin in epithelial
malignancies and sarcomas that frequently metastasize to the thorax.

Primary Objectives:

- Phase I component: To determine pharmacokinetics, toxicities, and maximum tolerated dose
(MTD) of mithramycin administered as a continuous 24hr infusion in patients with primary
thoracic malignancies or carcinomas, sarcomas or germ cell tumors metastatic to the
chest.

- Phase II component: To determine objective response rates (CR+PR) of mithramycin
administered as 24h intravenous infusions in patients with primary thoracic malignancies
or carcinomas, sarcomas or germ cell tumors metastatic to the chest.

Eligibility:

- Patients with histologically or cytologically proven primary malignancies involving
lungs, esophagus, thymus, pleura, chest wall or mediastinum, or extra-thoracic
malignancies metastatic to the chest.

- Patients with germline SNPs in ABCB4 and ABCB11 that are associated with resistance to
mithramycin-induced hepatotoxicity.

- Patients must have had or refused first-line standard therapy for their malignancies.

- Patients must be 18 years or older with an ECOG performance status of 0-2, without
evidence of unstable or decompensated myocardial disease. Patients must have adequate
pulmonary reserve evidenced by FEV1 and DLCO equal to or greater than 30% predicted;
pCO2 less than 55 mm Hg and pO(2) greater than or equal to 60 mm Hg on room air ABG.

- Patients must have a platelet count greater than or equal to 100,000, an ANC equal to or
greater than 1500 without transfusion or cytokine support, a normal PT, and adequate
hepatic function as evidenced by a total bilirubin of <1.5 times upper limits of normal.
Serum creatinine within normal institutional limits or creatinine clearance greater than
or equal to 60 mL/min/1.73 m(2) for patients with creatinine levels above institutional
normal

Design:

- Single arm Phase I dose escalation to define pharmacokinetics, toxicities and MTD.

- Patient cohorts will receive 24h infusions of mithramycin targeting total doses
currently administered during 7 daily six hour infusions at 30-50mcg/kg.

- The 24 h infusions will be administered every 14 days (1 cycle). Four cycles will
constitute one course of therapy.

- Pharmacokinetics and toxicity assessment to define MTD will be assessed during cycle 1
of the first course of therapy.

- Due to uncertainties regarding potential cumulative toxicities, no intra-patient dose
escalation will be allowed.

- Once MTD has been defined, patients will be enrolled into two cohorts (primary thoracic
malignancy vs neoplasm of non-thoracic origin metastatic to the chest) to determine
clinical response rates at the MTD, using a Simon Optimal Two Stage Design for Phase II
Clinical Trials targeting an objective response rate (RECIST) of 30%.

- Following each course of therapy, patients will undergo restaging studies. Patients
exhibiting objective response to therapy or stable disease by RECIST criteria will be
offered an additional course of therapy.

- Patients exhibiting disease progression will be removed from study.

- Biopsies of index lesions will be obtained at baseline and on day 4 of the first and if
feasible second cycle of therapy for analysis of pharmacodynamic endpoints. An
additional biopsy may be requested in patient exhibiting objective responses following
one course of therapy.

- INCLUSION CRITERIA:

- Diagnosis: Patients with measurable inoperable, histologically confirmed non-small
cell lung cancer (NSCLC), small cell lung cancer (SCLC), esophageal carcinoma, thymic
epithelial neoplasms, germ cell tumors, malignant pleural mesotheliomas or chest wall
sarcomas, as well as patients with gastric, colorectal, pancreas or renal cancers,
germ cell tumors and sarcomas metastatic to thorax are eligible.

- Histologic confirmation of disease in the Laboratory of Pathology, CCR, NCI, NIH.

- Germline ABCB4 (CC) and ABCB11 (GG or GC) genotypes determined by pharmacogenomics
analysis of peripheral blood mononuclear cells.

- Disease amenable to biopsy via percutaneous approach or other minimally invasive
procedures such as thoracoscopy, bronchoscopy, laparoscopy, or GI endoscopy

- Age greater than or equal to18

- ECOG status 0-2

- Patients must have had, or refused first-line standard chemotherapy for their
inoperable malignancies.

- Patients must have had no chemotherapy, biologic therapy, or radiation therapy for
their malignancy for at least 30 days prior to treatment. Patients may have received
localized radiation therapy to non-target lesions provided that the radiotherapy is
completed 14 days prior to commencing therapy, and the patient has recovered from any
toxicity. At least 3 half-lives must have elapsed since monoclonal antibody treatment.
At least six weeks must have elapsed between mitomycin C or nitrosourea treatment.

- Patients must have adequate organ and marrow function as defined below:

1. Hematologic and Coagulation Parameters:

- Peripheral ANC greater than or equal to 1500/mm(3)

- Platelets greater than or equal to 100,000/ mm(3) (transfusion independent)

- Hemoglobin greater than or equal to 8 g/dL (PRBC transfusions permitted)

- PT/PTT within normal limits ( 11.6 - 15.2 / 25.3 - 37.3 sec)

2. Hepatic Function

- Bilirubin (total) < 1.5 times upper limit of normal (ULN)

- ALT (SGPT) less than or equal to 3.0 times ULN

- Albumin > 2 g/dL

3. Renal Function

- Creatinine within normal institutional limits or creatinine clearance
greater than or equal to 60 mL/min/1.73 m(2) for patients with creatinine
levels above institutional normal.

- Normal ionized calcium, magnesium and phosphorus (can be on oral
supplementation)

- Cardiac Function: Left ventricular ejection fraction (EF) >40% by echocardiogram,
MUGA, or cardiac MR.

- Ability of subject to understand, and be willing to sign informed consent

- Female and male patients (and when relevant their partners) must be willing to
practice birth control (including abstinence) during and for two months after
treatment if female of childbearing potential or male having sexual contact with a
female of childbearing potential.

- Patients must be willing to undergo 2 tumor biopsies

EXCLUSION CRITERIA:

- Clinically significant systemic illness (e.g. serious active infections or significant
cardiac, pulmonary, hepatic or other organ dysfunction), that in the judgment of the
PI would compromise the patient s ability to tolerate protocol therapy or
significantly increase the risk of complications

- Patients with cerebral metastases

- Patients with any of the following pulmonary function abnormalities will be excluded:

FEV, < 30% predicted; DLCO, < 30% predicted (post-bronchodilator); pO2 < 60 mm Hg or pCO2
greater than or equal to 55 mm Hg on room air arterial blood gas.

- Patients with evidence of active bleeding, intratumoral hemorrhage or history of
bleeding diatheses, unless specifically occurring as an isolated incident during
reversible chemotherapy-induced thrombocytopenia

- Patients on therapeutic anticoagulation Note: prophylactic anticoagulation (i.e.
intralumenal heparin) for venous or arterial access devices is allowed.

- Patients who are concurrently receiving or requiring any of the following agents,
which may increase the risk for mithramycin related toxicities, such as hemorrhage:

- Thrombolytic agents

- Aspirin or salicylate-containing products, which may increase risk of hemorrhage

- Dextran

- Dipyridamole

- Sulfinpyrazone

- Valproic acid

- Clopidogrel

- Lactating or pregnant females (due to risk to fetus or newborn, and lack of testing
for excretion in breast milk).

- Patients with history of HIV, HBV or HCV due to potentially increased risk of
mithramycin toxicity in this population.

- Hypersensitivity to mithramycin

- Patients who in the opinion of the investigator may not be able to comply with the
safety monitoring requirements of the study.