Intralesional 5-Fluorouracil (5FU), Topical Imiquimod Treatment for SCC

Squamous cell carcinoma (SCC) of the lower extremity is a distinct subset of cutaneous
squamous cell carcinomas which tend to occur multiply in elderly women. In contrast, the
majority of cutaneous SCCs occur on the head and neck, and in men more than women.
Histopathological studies of lower extremity SCCs revealed that they tend to be well
differentiated and have low incidence of perineural and lymphovascular invasion. SCCs of the
lower extremity are also less prone to metastasis. Surgical excision has been the mainstay in
the treatment of SCC, including lower extremity SCC. However, the lower extremity, as a site,
is prone poor wound healing and postoperative complications such as infections. Furthermore,
a phenomenon called eruptive postoperative SCC can occur, in which cytokines released during
wound healing trigger secondary tumor formation in genetically predisposed cells surrounding
the original SCC. Given that lower extremity SCCs are less aggressive but more prone to
surgical complications when excised, the investigators believe these types of lesions may be
good candidates for non-surgical treatment.

5-fluorouracil (5FU) is a chemotherapeutic agent that has been used systemically for various
malignancies, but it has also been used topically or intralesionally for a variety of
dermatological conditions. But reports of its use in invasive cutaneous SCC, other than in
keratoacanthomas, are very limited. The investigators are aware of 3 such reports in the
literature. In the largest study to date, 6 weekly intralesional injections of
5FU-epinephrine gel were performed on 23 patients with cutaneous SCC on various body sites,
22 (96%) of whom demonstrated histologically confirmed tumor clearance. This study, however,
used a proprietary gel formulation which is not widely available. There are two other case
reports of successful treatment of SCC with 6-8 intralesional injections of 5FU at weekly
intervals. The three published studies injected 0.6ml to 2.4ml of 5FU, per each weekly
session, at concentrations of 30mg/ml to 50mg/ml.

Imiquimod is a topical immune response modulator which acts through the toll-like-receptor 7
pathway. It is FDA approved for the treatment actinic keratosis, genital warts, and
superficial basal cell carcinomas. It has also been used off-label for the treatment of
squamous cell carcinomas in situ and invasive cutaneous squamous cell carcinomas. A review of
published studies to date found 50-88% clearance rate for squamous cell carcinomas in situ
treated with daily application of topical imiquimod. There is only one study, other than case
reports of treating invasive squamous cell carcinomas with topical imiquimod. In that study,
7 out of 12 (71%) invasive squamous cell carcinomas cleared with topical imiquimod 5 days per
week for 12 weeks. Common reported adverse reactions are erythema, pruritus, weeping,
erosions, crusting at the application site.

The aim of the proposed study is to evaluate a relatively unexplored approach to treatment of
SCC on the lower extremities. The strategy is to directly and specifically deliver a drug to
the tumor through an injection weekly for three weeks. For the proposed phase I clinical
trial, the investigators will perform intralesional injections of a well-characterized,
potent chemotherapeutic agent (5-fluorouracil) to kill topically accessible SCC cells.
Importantly, 5-fluorouracil is currently in clinical use with a well-established safety
profile. It is anticipated that intralesional injections of 5-fluorouracil (5FU) will enable
direct and specific delivery of chemotherapy to the tumor, thereby reducing the potential for
systemic toxicity. Further, intralesional injections of 5FU enable tumoral delivery of
locally effective concentrations of 5FU using doses that are orders of magnitude below those
used currently for the intravenous (IV) treatment of multiple malignancies.

In addition to the 5FU injections, a subset of study participants will also have their
lesions treated with a topical application of 5% imiquimod, another well-characterized
chemotherapeutic agent with some demonstrated efficacy in treating cutaneous squamous cell
carcinomas. The investigators hope that the concomitant use of topical 5% imiquimod will work
synergistically with intralesional 5FU. No study published to date has been found on the
concomitant use of intralesional 5FU and topical imiquimod.

Participants will have at least 1 SCC lesion greater 1cm and less than 2 cm in largest
diameter, on their lower extremities. The clinical diagnosis of SCC will be confirmed
histologically by a deep shave biopsy of less than half of the lesion. The remainder of the
lesion will be used for intralesional injections of 5FU or intralesional 5FU/topical
imiquimod according to the following schema:

In this study, a total of 30 participants will be randomly assigned into 3 groups.
Randomization will be conducted using the University of Pittsburgh Cancer Institute (UPCI)
randomizer, which is maintained by the Biostatistics Facility of UPCI
(https://randomize.upci.pitt.edu/randomizer/home.seam).10 participants will serve as a
control group, and will receive neither 5FU injection nor topical imiquimod. In another 10
participants, intralesional injections of 50mg of 5FU in 1ml aqueous injectable solution will
be administered weekly for 3 weeks. In yet another 10 participants, intralesional 5FU will be
administered as in the previous group, additionally participants will also receive
three-times-weekly topical application of 5% imiquimod to the same lesion. At the end of week
two, a 2mm punch biopsy of the lesion will be obtained for mid-point analysis, and will be
stored for tissue banking and future study. A week after the last injection (week 4), the
lesion will be surgical resected in all participants including the control group, to render
the patients disease free. Resection is the current standard of care for these tumors. A part
of, or all of, the resected tumor and surrounding skin will be stored for tissue banking and
future studies to characterize and compare the tumor microenvironment before, during, and
after therapy.

All lesions will be photographed and treatment response will be evaluated 4 weeks after the
first 5FU injection prior to excision.

Inclusion Criteria:

- Biopsy-confirmed SCC more than 1.0 cm and less than 2.0 cm in diameter in the lower
extremities, defined as the knees and below.

- Subjects must have an expected survival of greater than or equal to12 months.

- Subjects must not be on any other investigational device/drug treatment.

- Subjects must to be willing to adhere to the instructions of the Investigator and his
research team and sign an Informed Consent Form prior to entry into the study.

- Patient is ≥ 18 years of age on day of signing informed consent.

- Patient must have a performance status of 0 or 1 on the Eastern Cooperative Oncology
Group (ECOG) Performance Scale.

- Female patient of childbearing potential has a negative urine or serum pregnancy test
within 7 days prior to receiving the first dose of study medication. If the urine test
is positive or cannot be confirmed as negative, a serum pregnancy test will be
required. The serum pregnancy test must be negative for the patient to be eligible.

- Female patients enrolled in the study, who are not free from menses for > 2 years,
post hysterectomy/oophorectomy, or surgically sterilized, must be willing to use
either 2 adequate barrier methods or a barrier method plus a hormonal method of
contraception to prevent pregnancy, or to abstain from heterosexual activity
throughout the study, starting with the first dose of study drug at visit 1 through
120 days after the last dose of study drug. Approved contraceptive methods include for
example: intra-uterine device, diaphragm with spermicide, cervical cap with
spermicide, male condoms, or female condom with spermicide. Spermicides alone are not
an acceptable method of contraception. Male patients must agree to use an adequate
method of contraception starting with the first dose of study drug through 120 days
after the last dose of study drug.

Exclusion Criteria:

- Patients with any evidence of nodal (Nx) and/or metastatic disease including distant
subcutaneous and/or lymph node metastases.

- Patients with primary non-cutaneous SCC - such as nasopharyngeal SCC.

- Patient with history of receiving organ transplantation.

- Patients with history of iatrogenic systemic immunosuppression.

- Patients with a history of skin or other disorder(s),that in the opinion of the
investigator, requires topical application of steroids and/or other creams/ointments.

- Patients with evidence of active infection - active and/or untreated hepatitis B/C,
HIV, etc - requiring systemic therapy.

- Patients with a known history of autoimmune disease.

- Patients with the following cardiac co-morbidities including:

- Baseline known prolongation of QT/QTc interval (QTc interval >500 msec).

- Heart failure either on clinical examination (manifestations include ascites,
cardiomegaly, dyspnea, edema, gallop rhythm, hepatomegaly, oliguria, pleural
effusion, pulmonary edema, tachycardia) or based on known decreased left
ventricular ejection fraction (LV EF) <50%.

- Patients who have had chemotherapy, radioactive or biological cancer therapy
within four weeks prior to the first dose of study drug, or who has not recovered
to Common Terminology Criteria for Adverse Events (CTCAE) Grade 1 or better from
the adverse effects (AEs) due to cancer therapeutics administered more than four
weeks earlier. Subjects with ≤ grade 2 neuropathy are an exception to this
criterion and may qualify for the study.

- If patient received major surgery, they must have recovered adequately from the
toxicity and/or complications from the intervention prior to starting therapy.

- Patients currently participating or who have participated in a study of an
investigational agent or using an investigational device within 4 weeks of the first
dose of study drug.

- Patients expected to require any other form of systemic or localized antineoplastic
therapy while on study.

- Patients with a known history of a hematologic malignancy, primary brain tumor or
sarcoma, or of another primary solid tumor, unless the patient has undergone
potentially curative therapy with no evidence of that disease for five years.

° The time requirement also does not apply to patients who underwent successful
definitive resection of basal or squamous cell carcinoma of the skin, superficial
bladder cancer, in situ cancers including cervical cancer, breast cancer, melanoma, or
other in situ cancers.

- Patients who have previously had a severe hypersensitivity reaction to 5-fluorouracil
or imiquimod.

- Serious illnesses, such as: cardiovascular disease (uncontrolled congestive heart
failure, hypertension, cardiac ischemia, myocardial infarction, and severe cardiac
arrhythmia), bleeding disorders, autoimmune diseases, severe obstructive or
restrictive pulmonary diseases, active systemic infections, and inflammatory bowel
disorders.

- Patients with a history or current evidence of any condition, therapy, or laboratory
abnormality that might confound the results of the study, interfere with the patient's
participation for the full duration of the study, or are not in the best interest of
the patient to participate, in the opinion of the treating Investigator.

- Patients who are, at the time of signing informed consent, regularly using illicit
drugs or are recently (within the last year) abusing illicit substances (including
alcohol).

- Patient is pregnant or breastfeeding, or expecting to conceive or father children
within the projected duration of the study.