Phase I Photodynamic Therapy (PDT) for Benign Dermal Neurofibromas (NF1)

Phase 1

Completed

Conditions: Neurofibromatoses

Interventions: Drug: Part 1 Levulan injection
Drug: Part 1 Levulan surface application
Drug: Part 1 Levulan surface application twice
Drug: Part 1 Levulan surface application twice with microneedling
Drug: Levulan (5-aminolevulinic acid) photodynamic therapy - Dose level 3
Drug: Levulan (5-aminolevulinic acid) photodynamic therapy - Dose level 1
Drug: Levulan (5-aminolevulinic acid) photodynamic therapy - Dose level 2

Registration Number: NCT01682811

Lead Sponsor: Harry T Whelan, MD

Brief Summary: GENERAL OBJECTIVE The general objective is to assess the safety and efficacy of photodynamic therapy (PDT) in the treatment of neurofibromatosis 1 (NF1) tumors in the skin.

SPECIFIC OBJECTIVE This is a light dose escalation pilot study to determine the safety and efficacy of PDT using 5-aminolevulinic acid (ALA) and 633 nm light in the treatment of benign dermal neurofibromas.

Specifically, the primary goal of the current study is to determine the maximum tolerable light doses that can be administered to subjects undergoing topical photoillumination photodynamic therapy with standard application of Levulan Kerastick (ALA) for Topical Solution.

Detailed Description: STUDY DESIGN This protocol is a Phase I light dose escalation pilot study to determine the safety and, secondarily, the efficacy of PDT using Levulan and 633 nm light in the treatment of benign dermal neurofibromas. This protocol represents the first two parts of a planned three part study including both pediatric and adult subjects. Part 1 will consist of studying the penetration and uptake of the PS in neurofibromas that are scheduled for excision. These tumors will be excised for therapeutic reasons unrelated to this study, and so this study will place no further burden on the subject other than a 3-24 hr incubation of the Levulan on the tumor prior to excision. The primary hypothesis to be tested is whether Levulan will accumulate, and be converted to PpIX, by the tumor tissue more than by the surrounding normal tissue. Secondary hypotheses are that tumors incubated with Levulan will show greater fluorescence than untreated tumors and tumors incubated with vehicle only (placebo application).

As the Institutional Review Boards involved generally desire pilot data on adult populations first, we will with then proceed with the adult clinical trial portion of this protocol as part 2. Part 2 will use the optimum incubation time, if one has been identified in part 1, and add a dose escalation study of the amount of red light used to activate the Levulan. Part 3, with pediatric subjects, will commence at a future date, pending review of the initial adult study results.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 20

Inclusion Criteria

Subjects with NF1 will be selected for photodynamic therapy on the following criteria.

Age: 18 years or older.
NF1 will be diagnosed by American Academy of Neurology guidelines.
Location of tumor: cutaneous, trunk or limbs only.
Tumor type: superficial dermal neurofibromas, less than or equal to 4 mm deep.
Growth confirmation: direct measurement for the dermal neurofibromas, ruler and photo-volumetric method.
Informed consent of subject.
Absence of any other malignancy.
Only failures to meet criteria 1-6 due to the primary disease will be disqualifying

Exclusion Criteria

Subjects will be excluded from participation in the study on the basis of the following:

Life expectancy less than 1 year.
Pregnancy.
Inability to consent.
Cutaneous photosensitivity to the wavelengths used to activate PDT.
A diagnosis of porphyria.
Allergy to aminolevulinic acid or any of the Topical Solution Vehicle components.
Previous chemotherapy within 6 weeks of proposed PDT.
Other concurrent tumor therapy. -

Study & Design

Study Type: INTERVENTIONAL

Study Design: SEQUENTIAL

Arm && Interventions

Group	Intervention	Description
Part 1 Levulan injection	Part 1 Levulan injection	5-aminolevulinic acid uptake by control lesions after Levulan vehicle (placebo) injection and 3 hr incubation, and by Levulan treated lesions after 3 or 24 hr incubation.
Part 1 Levulan painting	Part 1 Levulan surface application	5-aminolevulinic acid uptake by control lesions after Levulan vehicle (placebo) surface application and 3 hr incubation, and by Levulan treated lesions and 3 or 24 hr incubation.
Part 1 Levulan painted twice	Part 1 Levulan surface application twice	5-aminolevulinic acid uptake by control lesions after Levulan vehicle (placebo) surface application twice or by Levulan treated lesions twice and 24 hr incubation.
Part 1 Levulan painted twice with microneedling	Part 1 Levulan surface application twice with microneedling	5-aminolevulinic acid uptake by control lesions after Levulan vehicle (placebo) surface application twice or by Levulan treated lesions twice and 24 hr incubation. All lesions prepared with microneedling.
Part 2 Dose level 3 200 J/cm^2	Levulan (5-aminolevulinic acid) photodynamic therapy - Dose level 3	Levulan (5-aminolevulinic acid) photodynamic therapy - Dose level 3 - 200 J/cm\^2 633 nm red light to Levulan vehicle (placebo) treated control lesions or Levulan treated lesions and 24 hr incubation. Follow-ups on day 2 for punch biopsies, 14-28 days for evaluation of cutaneous adverse events, and every 3 months up to one year for lesion measurements.
Part 2 Dose level 1 50 J/cm^2	Levulan (5-aminolevulinic acid) photodynamic therapy - Dose level 1	Levulan (5-aminolevulinic acid) photodynamic therapy - Dose level 1 - 50 J/cm\^2 633 nm red light to Levulan vehicle (placebo) treated control lesions or Levulan treated lesions and 24 hr incubation. Follow-ups on day 2 for punch biopsies, 14-28 days for evaluation of cutaneous adverse events, and every 3 months up to one year for lesion measurements.
Part 2 Dose level 2 100 J/cm^2	Levulan (5-aminolevulinic acid) photodynamic therapy - Dose level 2	Levulan (5-aminolevulinic acid) photodynamic therapy - Dose level 2 - 100 J/cm\^2 633 nm red light to Levulan vehicle (placebo) treated control lesions or Levulan treated lesions and 24 hr incubation. Follow-ups on day 2 for punch biopsies, 14-28 days for evaluation of cutaneous adverse events, and every 3 months up to one year for lesion measurements.

Primary Outcome Measures

Name	Time	Method
Part 1: Photosensitizer Uptake and Conversion to Protoporphyrin IX	24 hours	The average fluorescence value for PpIX positive tumor areas in excised, sectioned tumors, as determined by fluorescence microscopy. PpIX signals were detected with excitation at 405 nm and emission with a 600 nm long pass filter. PpIX positive areas were determined to be those exhibiting fluorescence above background levels.
Part 2: Maximum Tolerated Dose (MTD) of 633 nm Red Light	48 hours	MTD was determined by testing increasing doses up to 200 J/cm\^2 on dose escalation cohorts 1 to 3 with 3 to 6 participants each. MTD reflects the highest dose of red light that did not cause a Dose-Limiting Toxicity (DLT) in \> 33% of participants. DLT was defined as pain during irradiation requiring cessation of the light treatment, or any serious cutaneous adverse events.

Secondary Outcome Measures

Name	Time	Method
Part 2: Cosmetic Improvement	1 year	Potential cosmetic improvement using subject satisfaction scale.
Part 2: Efficacy - Lesion Area Growth Rate	12 weeks	Average lesion growth rates observed in ALA-treated lesions compared to vehicle-treated lesions within the same subjects.
Part 2: Pain Reduction	1 year	Potential pain reduction, as measured by standard visual analog 1-10 scale.
Part 1: Optimal Occlusion Time	24 hours	An optimal occlusion time may be apparent from the results of the three time points. If no optimal occlusion time is seen, any occlusion time from 3-24 hours may be chosen for part 2. This secondary outcome measure is not critical to continuing the study, but may be useful in guiding treatment protocols