Breast Cancer, Melanoma
Conditions
Keywords
breast cancer, lymph nodes, melanoma, surgery
Brief summary
Data from this pivotal clinical trial will be used to support a marketing application (i.e., NDA) for Navidea's Lymphoseek for use in intraoperative localization of lymph tissue (nodes) in the lymphatic pathway draining the primary site of a tumor.
Detailed description
In patients with primary melanoma and breast cancer, lymph node status is often a strong predictor of outcome and influences the course of treatment a patient may follow after surgery. In an effort to reduce the morbidity and costs of detection of lymph node metastases, surgical oncologists have developed a method by which the sentinel lymph node (the first node in a draining basin) is identified intraoperatively and removed. This technique, called sentinel node biopsy, has extremely high negative predictive values for melanoma metastases and breast cancer metastases. The two largest trials for melanoma, Morton, et al (2005) and Rossi, et al (2006), reported false negative rates of 6.3% and 14.7%, respectively. Morton, et al (2006), in perhaps the most mature trial reported to date, showed a false negative rate of 3.4% . There is growing evidence that sentinel node biopsy will have a significant impact on the management of melanoma. Sentinel node biopsy also has extremely high negative predictive values for breast cancer metastases; the false-negative rates range from 0% to 9%. There is growing evidence that sentinel node biopsy will have a significant impact on the management of breast cancer. Although the survival and local recurrence studies have yet to be completed, the technique has emerged into common practice. Lymphatic mapping with a radiopharmaceutical is a nuclear medicine examination which identifies for the surgeon the first lymph node to receive lymphatic flow from the primary tumor site. This node is removed and analyzed for the presence of malignant cells. By locating the lymph node prior to surgery, a small incision can be used to remove the node and a smaller dissection can be employed. The high negative predictive value of the technique seems to provide an accurate staging procedure and may spare patients who are lymph node negative the morbidity of a complete lymph node dissection. Consequently, staging of melanoma by lymph node mapping and biopsy may be equivalent to regional node dissection without the attendant post surgical morbidity. An ideal lymph node imaging agent would exhibit rapid clearance from the injection site, rapid uptake and high retention within the first draining lymph node, and low uptake by the remaining lymph nodes. The ideal agent would also have low radiation absorption; high biological safety; convenient, rapid, and stable technetium-99m labeling; and biochemical purity. Lymphoseek (technetium-99m-labeled diethylenetriamine pentaacetic acid-mannosyl-dextran, \[Tc-99m\]DTPA-mannosyl-dextran) is a radiotracer that accumulates in lymphatic tissue by binding to a mannose-binding protein that resides on the surface of dendritic cells and macrophages. Lymphoseek is a macromolecule consisting of multiple units of DTPA and mannose, each synthetically attached to a 10 kilodalton dextran backbone. The mannose acts as a substrate for the receptor, and the DTPA serves as a chelating agent for labeling with Tc-99m.
Interventions
DRUGLymphoseek
Breast Cancer: Intradermal admin of Lymphoseek: Inject 0.2-0.4 mL in multiple divided injections or a single injection overlying the intact primary tumor or excision biopsy site OR periareolar administration of Lymphoseek: Inject 0.2-.04 mL in multiple divided doses at the margin of the areola OR subareolar administration of Lymphoseek: Inject 0.2-0.4 in multiple divided injections or a single injection in subareolar area as a subcutaneous injection OR peritumor administration of Lymphoseek: Inject 2.0-4.0 mL in multiple divided injections, intraparenchemally surrounding the tumor or biopsy cavity. For melanoma pts intradermal administration of Lymphoseek: Inject 0.2-0.4 mL in multiple divided injections or a single injection overlying the intact primary tumor or excision biopsy site.
Sponsors
Navidea Biopharmaceuticals
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* The patient has provided written informed consent with HIPAA authorization before participating in the study, as has his/her responsible caregiver, if applicable. * The patient is a candidate for surgical intervention, with lymph node mapping being a part of the surgical plan. * The patient is at least 18 years of age at the time of consent. * The patient has an ECOG performance status of Grade 0 - 2 \[8\]. * The patient has a clinical negative node status at the time of study entry. * If of child bearing potential, the patient has a negative pregnancy test within 72 hours prior to administration of Lymphoseek, has been surgically sterilized, or has been postmenopausal for at least 1 year. * The patient is currently not participating in another investigational drug study. Melanoma Patients * The patient has a diagnosis of primary melanoma. Breast Cancer Patients * The patient has a diagnosis of primary breast cancer. * Patients with pure ductal carcinoma in situ (DCIS) or non-invasive carcinoma if lymph node biopsy is part of the surgical plan.
Exclusion criteria
* The patient is pregnant or lactating; * The patient has clinical or radiological evidence of metastatic cancer including palpably abnormal or enlarged lymph nodes (i.e., all patients should be any T,N0,M0); * The patient has a known hypersensitivity to Lymphazurin or Patent Bleu V. Melanoma Patients * The patient has a tumor with a Breslow depth less than 0.75mm.; * Patients that have had preoperative chemotherapy, immunotherapy or radiation therapy; * Patients diagnosed with a prior invasive melanoma that would occur on the same body region or potentially draining to the same nodal basin or patients with truncal or extremity primary melanoma who has had a prior breast cancer potentially draining to the same axillary nodal basin; * Patients who have undergone node basin surgery of any type or radiation to the nodal basin(s) potentially draining the primary melanoma; * Patients who have undergone a wide excision for their primary melanoma (\>1 cm in dimension) or complex reconstruction (rotation, free flap or skin graft of any type). Breast Cancer Patients * The patient has bilateral primary breast cancers or multiple tumors within their breast; * Patients that have had prior surgical procedures such as breast implants, reduction mammoplasty or axillary surgery; * Patients scheduled for bilateral mastectomy for any reason; * Patients that have had preoperative radiation therapy to the affected breast or axilla
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Concordance of Blue Dye and Lymphoseek | Surgery after injections of Lymphoseek and blue dye | The proportion of lymph nodes detected intraoperatively by blue dye that were also detected by Lymphoseek. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Reverse Concordance of Blue Dye and Lymphoseek | Surgery after injections of Lymphoseek and blue dye | The proportion of lymph nodes detected intraoperatively by Lymphoseek that were also detected by blue dye. |
Countries
Israel, United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Lymphoseek Enrolled patients who were administered any injection of Lymphoseek. | 179 |
| Total | 179 |
Baseline characteristics
| Characteristic | Lymphoseek |
|---|---|
| Age, Categorical <=18 years | 0 Participants |
| Age, Categorical >=65 years | 59 Participants |
| Age, Categorical Between 18 and 65 years | 120 Participants |
| Age Continuous | 58.5 years STANDARD_DEVIATION 14.1 |
| Region of Enrollment Israel | 18 participants |
| Region of Enrollment United States | 161 participants |
| Sex: Female, Male Female | 128 Participants |
| Sex: Female, Male Male | 51 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | — / — |
| other Total, other adverse events | 10 / 179 |
| serious Total, serious adverse events | 4 / 179 |
Outcome results
Primary
Concordance of Blue Dye and Lymphoseek
The proportion of lymph nodes detected intraoperatively by blue dye that were also detected by Lymphoseek.
Time frame: Surgery after injections of Lymphoseek and blue dye
Population: All enrolled patients who were injected with both Lymphoseek and blue dye, who underwent surgery and had at least one lymph node stained intraoperatively by blue dye, and for whom the tissue type (lymphatic/nonlymphatic) and pathology status (presence/absence of tumor cells) was confirmed.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Intent-To-Treat | Concordance of Blue Dye and Lymphoseek | 0.9767 Proportion of Lymph Nodes |
Secondary
Reverse Concordance of Blue Dye and Lymphoseek
The proportion of lymph nodes detected intraoperatively by Lymphoseek that were also detected by blue dye.
Time frame: Surgery after injections of Lymphoseek and blue dye
Population: All enrolled patients who were injected with both Lymphoseek and blue dye, who underwent surgery and had at least one lymph node detected by Lymphoseek (at ≥ 3σ count) in vivo, and for whom the tissue type (lymphatic/non-lymphatic) and pathology status (presence/absence of tumor cells) was confirmed.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Intent-To-Treat | Reverse Concordance of Blue Dye and Lymphoseek | 0.6863 Proportion of Lymph Nodes |