topical sinecatechins ointment in treatment of primary ... · protocol title ‘topical...

NL47392.068.13 Groene thee zalf studie

Topical Sinecatechins Ointment In Treatment

Of Primary Superficial Basal Cell Carcinoma

(July 2014)

Downloaded From: https://jamanetwork.com/ by a Non-Human Traffic (NHT) User on 10/04/2020


PROTOCOL TITLE ‘Topical sinecatechins in the treatment of primary superficial basal cell

carcinoma: a double blind, randomised, placebo-controlled trial’

Protocol ID NL 47392.068.13

Short title Topical sinecatechins in the treatment of

superficial basal cell carcinoma

EudraCT number 2013-005439-26

Version 3

Date July 15th 2014

Coordinating investigator/project

leader

K.J.A. Frencken, MD

Medical Doctor

Department of Dermatology Maastricht UMC

Email: [email protected]

Tel: 0031 43 3877295

Principal investigator(s) (in

Dutch: hoofdonderzoeker/

uitvoerder)

Dr. N.W.J. Kelleners-Smeets, MD, PhD

Dermatologist



Tel.: 0031 43 3877295

Dr. K. Mosterd, MD, PhD

Dermatologist



Tel.: 0031 43 3877295

Sponsor (in Dutch:

verrichter/opdrachtgever)

Academisch ziekenhuis Maastricht (azM)

Subsidising party WILL PHARMA

Independent expert (s) I.F. Nagtzaam


mailto:[email protected]




Dermatologist



Tel.: 0031 43 3877289

Laboratory sites Dr. V.J.L. Winnepenninckx

Pathologist

Department of Pathology Maastricht UMC


Pharmacy (Manufacturer)

Marketing authorisation holder

Relabeling tubes

MediGene AG (München, Germany)

Michaela Fabry

Director Commercial Operations and Supply

Chain Management


Tel: 0049 89 20 00 33 33 22

WILL PHARMA (Zwanenburg, The Netherlands)

Karel Bouwens

Director Sales and Marketing


Tel: 0031 (0)20 4976551

Apotheek Radboud UMC (Nijmegen, The

Netherlands)

Maren Blonk








Statistics Dr. P.J. Nelemans

Epidemiologist

Maastricht University




PROTOCOL SIGNATURE SHEET

Name Signature Date

Head of Department:

Prof. Dr. P.M. Steijlen

Dermatologist

Department of Dermatology Maastricht

UMC


Tel.: 0031 43 3875292

Handtekening Datum

Principal Investigator:

Dr. N.W.J. Kelleners-Smeets, MD, PhD

Dermatologist

Department of Dermatology Maastricht

UMC


Tel.: 0031 43 3877295

Handtekening Datum





TABLE OF CONTENTS

1. INTRODUCTION AND RATIONALE ................................................................................ 12

2. OBJECTIVES .................................................................................................................... 14

3. STUDY DESIGN ............................................................................................................... 15

4. STUDY POPULATION...................................................................................................... 17

4.1 Population (base)....................................................................................................... 17

4.2 Inclusion criteria ......................................................................................................... 17

4.3 Exclusion criteria........................................................................................................ 17

4.4 Sample size calculation ............................................................................................. 18

5. TREATMENT OF SUBJECTS .......................................................................................... 19

5.1 Investigational product/treatment .............................................................................. 19

5.2 Use of co-intervention ................................................................................................ 19

5.3 Escape medication .................................................................................................... 20

6. INVESTIGATIONAL PRODUCT ....................................................................................... 21

6.1 Name and description of investigational products ................................................... 21

6.2 Summary of findings from non-clinical studies.......................................................... 21

6.3 Summary of findings from clinical studies ................................................................. 22

6.4 Summary of known and potential risks and benefits ................................................ 23

6.5 Description and justification of route of administration and dosage ......................... 23

6.6 Dosages, dosage modifications and method of administration ................................ 23

6.7 Preparation and labelling of Investigational Medicinal Product ................................ 23

6.8 Drug accountability .................................................................................................... 24

7. NON-INVESTIGATIONAL PRODUCT ............................................................................. 25

7.1 Name and description of non-investigational product(s) .......................................... 25

7.2 Summary of findings from non-clinical studies.......................................................... 25

7.3 Summary of findings from clinical studies ................................................................. 25

7.4 Summary of known and potential risks and benefits ................................................ 25

7.5 Description and justification of route of administration and dosage ......................... 25

7.6 Dosages, dosage modifications and method of administration ................................ 25

7.7 Preparation and labelling of Non Investigational Medicinal Product ........................ 25

7.8 Drug accountability .................................................................................................... 25

8. METHODS ........................................................................................................................ 26

8.1 Study parameters/endpoints ..................................................................................... 26

8.1.1 Main study parameter/endpoint ......................................................................... 26

8.1.2 Secondary study parameters/endpoints ............................................................ 26

8.1.3 Other study parameters ..................................................................................... 27

8.2 Randomisation, blinding and treatment allocation .................................................... 27

8.3 Study procedures....................................................................................................... 28

8.4 Withdrawal of individual subjects .............................................................................. 29

8.4.1 Specific criteria for withdrawal (if applicable) ..................................................... 29

8.5 Replacement of individual subjects after withdrawal ................................................ 29

8.6 Follow-up of subjects withdrawn from treatment ...................................................... 30



8.7 Premature termination of the study ........................................................................... 30

9. SAFETY REPORTING...................................................................................................... 31

9.1 Section 10 WMO event .............................................................................................. 31

9.2 AEs, SAEs and SUSARs ........................................................................................... 31

9.2.1 Adverse events (AEs)......................................................................................... 31

9.2.2 Serious adverse events (SAEs) ......................................................................... 31

9.2.3 Suspected unexpected serious adverse reactions (SUSARs) .......................... 32

9.3 Annual safety report .................................................................................................. 33

9.4 Follow-up of adverse events ..................................................................................... 33

9.5 [Data Safety Monitoring Board (DSMB) / Safety Committee] ................................... 33

10. STATISTICAL ANALYSIS ............................................................................................. 34

10.1 Primary study parameter(s) ....................................................................................... 34

10.2 Secondary study parameter(s) .................................................................................. 34

10.3 Other study parameters ............................................................................................. 34

10.4 Interim analysis (if applicable) ................................................................................... 35

11. ETHICAL CONSIDERATIONS ..................................................................................... 36

11.1 Regulation statement ................................................................................................. 36

11.2 Recruitment and consent........................................................................................... 36

11.3 Objection by minors or incapacitated subjects.......................................................... 36

11.4 Benefits and risks assessment, group relatedness .................................................. 36

11.5 Compensation for injury............................................................................................. 37

11.6 Incentives ................................................................................................................... 37

12. ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION .......................... 38

12.1 Handling and storage of data and documents .......................................................... 38

12.2 Monitoring and Quality Assurance ............................................................................ 38

12.3 Amendments .............................................................................................................. 38

12.4 Annual progress report .............................................................................................. 39

12.5 End of study report .................................................................................................... 39

12.6 Public disclosure and publication policy .................................................................... 39

13. STRUCTURED RISK ANALYSIS ................................................................................. 40

13.1 Potential issues of concern ....................................................................................... 40

13.2 Synthesis ................................................................................................................... 42

14. REFERENCES .............................................................................................................. 42



Version 3: July 15th 2014 8 of 44

LIST OF ABBREVIATIONS AND RELEVANT DEFINITIONS

ABR ABR form, General Assessment and Registration form, is the application

form that is required for submission to the accredited Ethics Committee (In

Dutch, ABR = Algemene Beoordeling en Registratie)

AE

BCC

Adverse Event

Basal Cell Carcinoma

CA Competent Authority

CCMO Central Committee on Research Involving Human Subjects; in Dutch:

Centrale Commissie Mensgebonden Onderzoek

CV Curriculum Vitae

DSMB

EGCG

Data Safety Monitoring Board

Epigallocatechin-3-gallate

EudraCT

FDA

FFPE

European drug regulatory affairs Clinical Trials

Food and Drug Administration

Formalin-fixed and paraffin-embedded

GCP

H&E

Hh

Good Clinical Practice

Haematoxylin & eosin

Hedgehog

IB Investigator’s Brochure

IC Informed Consent

METC

MUMC

PDT

PTCH1

Medical research ethics committee (MREC); in Dutch: medisch ethische

toetsing commissie (METC)

Maastricht University Medical Centre

Photodynamic Therapy

Patched 1

(S)AE (Serious) Adverse Event

sBCC

SMO

SUFU

Superficial Basal Cell Carcinoma

Smoothened

Suppressor of Fused

SPC Summary of Product Characteristics (in Dutch: officiële productinfomatie

IB1-tekst)

Sponsor The sponsor is the party that commissions the organisation or performance

of the research, for example a pharmaceutical

company, academic hospital, scientific organisation or investigator. A party

that provides funding for a study but does not commission it is not




regarded as the sponsor, but referred to as a subsidising party.

SUSAR Suspected Unexpected Serious Adverse Reaction

WMO Medical Research Involving Human Subjects Act (in Dutch: Wet Medisch-

wetenschappelijk Onderzoek met Mensen




SUMMARY

Rationale: Basal cell carcinoma (BCC) is the most frequently occurring nonmelanoma skin

cancer in Caucasians, representing approximately 80% of cases. Incidence rates for men

and women in the Netherlands are 165 and 157 per 100,000 person-years respectively and

are still rising 3-10% annually. In 2009, the lifetime risk for developing a first histologically

confirmed BCC for men was approximately 1 in 5 (21%) and for women it was 1 in 6 (18%).

A simplified classification of BCC includes the following three histological subtypes: nodular

(40,6), superficial (30,7%) and infiltrative BCC (28,7%). Superficial BCCs (sBCCs) differ from

the other subtypes as they tend to appear at a younger age, usually occur on the trunk and

are often multiple. This subtype has the fastest growing incidence.

A characteristic feature of BCCs is their low risk to metastasize, though if untreated they may

induce considerable functional and cosmetic morbidity as they are locally invasive. Surgery is

the first treatment of choice for BCC. However due to the rising incidence and the extensive

workload this entails, a non-invasive topical treatment is often chosen for sBCC as they grow

down from the epidermis into the superficial dermis and therefore are easily accessible for

topical treatment. Photodynamic therapy (PDT), imiquimod cream or 5-fluorouracil cream are

available topical treatments for sBCC however their tumour free survival rates are not equal

to the higher tumour free survival rates of surgical treatment yet. Next to the efficacy, the now

available topical treatments are associated with local skin reactions at the treatment site,

mainly erythema and erosion (imiquimod cream and 5-fluorouracil cream) or pain and

burning sensation (PDT). This creates the need for additional or alternative non-invasive

topical treatments.

Primary Objective: To determine whether topical sinecatechins 10% (Veregen®) ointment

application can lead to a histological regression (efficacy) of a superficial basal cell

carcinoma.

Secondary Objectives: To assess compliance and adverse reactions (safety). To assess

other histological effects with additional immunohistochemic stains; Bcl-2 (anti-apoptosis),

Ki67 (proliferation).

Study design: Clinical double blind, randomized, placebo-controlled intervention trial

Study population: Male and female outpatients, aged 18 years or older without serious

comorbidities of the Dermatology department of MUMC+, The Netherlands, with histological

proven primary superficial basal cell carcinoma ≥ 4mm < 20mm outside the H-zone of the

face and scalp.

Intervention (if applicable): One group receives sinecatechins 10% ointment twice daily for

six weeks and the other group receives placebo twice daily for six weeks.




Main study parameters/endpoints: The main study parameter is percentage histological

regression of the target tumour. This will be analysed by comparing the proportion of patients

with complete histological regression in the treatment group to placebo group assessed by

independent blinded dermato-pathologists.

Compliance, number of local skin reactions, adverse events and serious adverse events and

histological effects of treatment with sinecatechins 10% ointment versus placebo will also be

assessed.

Nature and extent of the burden and risks associated with participation, benefit and

group relatedness: First visit, punch biopsy, telephonic consultation and surgical excision

are part of regular care of superficial basal cell carcinoma. Treatment with sinecatechins

ointment or placebo, inclusion visit and two control visits are part of the study.

A potential risk when participating in this study is an allergy for one of the components of the

sinecatechins 10% ointment or placebo.

Local skin reactions at application site represent a special safety issue for topically applied

treatments. Therefore we will evaluate and describe local skin reactions separately from

other adverse events. Local skin reactions can be easily controlled and therefore are

acceptable for the subjects. We do not expect any other risks.




1. INTRODUCTION AND RATIONALE

Basal cell carcinoma (BCC) is the most frequently occurring nonmelanoma skin cancer in

Caucasians, representing approximately 80% of cases.1 Incidence rates for men and women

in the Netherlands are 165 and 157 per 100,000 person-years respectively and are still rising

3-10% annually.1,2 In 2009, the lifetime risk for developing a first histologically confirmed BCC

for men was approximately 1 in 5 (21%) and for women it was 1 in 6 (18%).2

A simplified classification of BCC includes the following three histological subtypes: nodular

(40,6%), superficial (30,7%) and infiltrative (28,7%) BCC.3,4 Superficial BCCs (sBCCs) differ

from the other subtypes as they tend to appear at a younger age, usually occur on the trunk

and are often multiple.5 This subtype has the fastest growing incidence.

A characteristic feature of BCCs is their low risk to metastasize, though if untreated they may

induce considerable functional and cosmetic morbidity as they are locally invasive. Surgery is

the treatment of first choice for all BCC subtypes. However, due to the rising incidence and

the extensive workload this entails, a non-invasive topical treatment is an often chosen

alternative for surgery for the superficial BCC subtype. As sBCCs grow down from the

epidermis into the superficial dermis, they are easily accessible for topical treatment.

Photodynamic therapy (PDT), imiquimod cream or 5-fluorouracil cream are available topical

treatments for sBCC, however their tumour free survival rates after one year follow-up are

not equal to the higher tumour free survival rates of surgical treatment.6,7 Next to the efficacy,

the now available topical treatments are associated with local skin reactions at the treatment

site, mainly erythema and erosion (imiquimod cream and 5-fluorouracil cream) or pain and

burning sensation (PDT).7 This creates the need for additional or alternative non-invasive

topical treatments.

The main exogenous predisposing risk factor of BCC is ultraviolet light exposure.8 However,

BCC tumourigenesis is multifactorial. The vast majority of BCCs occur sporadically.

Approximately 90% of sporadic BCCs have identifiable mutations in at least one allele of the

patched 1 (PTCH1) gene, an inhibitor of the Hedgehog (Hh) signalling pathway9. This

relieves the inhibition of smoothened (SMO) by PTCH1 and SMO sends signals through a

series of interacting proteins, including suppressor of fused (SUFU), resulting in activation of

the downstream Gli family of transcription factors, leading to proliferation9.

A recent study presents convincing evidence that canonical Wingless-type MMTV integration

site (Wnt) signalling pathway is essential for a tumorigenic response to deregulated Hh

signalling in skin.10 Several earlier studies also report a link between the Hh and Wnt

pathways in BCC.11,12 The canonical Wnt pathway regulates the ability of the β-catenin

protein to accumulate and enter the nucleus, where it interacts with proteins and converts

them into transcriptional activators, leading to proliferation.13

The tumour suppressor gene p53, which controls the intrinsic pro-apoptotic pathway, is

mutated in 40% of sporadic BCCs.14

The active constituents of green tea are promising because of their supposed anti-BCC-

carcinogenesis effects as described by several epidemiological, cell culture and animal




studies.15,16 The so-called polyphenols known as catechins are the active constituents of

green tea and the catechin epigallocatechin-3-gallate (EGCG) is the major and most active

catechin. EGCG is thought to have a cytotoxic effect on skin cancer cells and has the

availability of inhibition of cell growth and induction of apoptosis.17-21 It is also suggested that

EGCG plays a role in inactivation of β-catenin signalling, an important component of the

WNT pathway.22

Sinecatechins 10% ointment (Veregen®) is a standardized extract of green tea leaves of the

species Camellia sinensis, containing mainly green tea polyphenols, particularly catechins

(more than 85%).23,24 The lead catechin in sinecatechins ointment is EGCG. It is approved by

the US Food and Drug Administration (FDA) for genital warts in adults.

There are no clinical trials on human subjects with topical EGCG on sBCC yet. With this trial

we are the first to try to validate the anti-carcinogenic potentials of topical EGCG in humans

with sBCC. We assess the effectiveness of sinecatechins 10% (Veregen®) versus placebo in

sBCCs. In case of effectivity, dose-response studies and head-to-head-comparison studies

with other topical available treatments will be needed to know the role of topical

sinecatechins 10% ointment as treatment for sBCCs.




2. OBJECTIVES

Primary Objective: To determine whether topical sinecatechins 10% (Veregen®) ointment

application can lead to a histological regression of a superficial basal cell carcinoma. This

will be analysed by comparing the proportion of patients with complete histological

regression in the treatment group versus the placebo group.

Secondary Objective(s): To assess compliance and adverse reactions (safety). To assess

histological effects with additional immunohistochemical stains; Bcl-2 (anti-apoptosis), Ki67

(proliferation).




3. STUDY DESIGN

The study will be a double blind, randomized, placebo-controlled intervention trial at the

Maastricht University Medical Centre (MUMC+) in the Netherlands. Patients with a primary,

histologically proven superficial basal cell carcinoma ≥ 4mm and < 20mm outside the H-zone

of the face will be randomly assigned to either sinecatechins 10% ointment or placebo and

instructed to apply the corresponding ointment two times daily for six weeks. Two weeks later

the tumour will be excised. The study will not interfere with clinical practice, because after

this trial all patients will be treated with surgical excision at two to three months after

diagnosis, which is the usual waiting time for excision.

A biopsy is taken to confirm the diagnosis of superficial BCC histologically by pathologists at

the Pathology department of the MUMC+. A superficial BCC is defined as small buds of

proliferating basal cells growing down from the epidermis into the superficial dermis, whilst

maintaining their attachment to the base of the epidermis 3.

Patients will receive instructions to apply sinecatechins 10% ointment twice daily in a thin

layer to the tumour including 5mm surrounding skin. Sinecatechins 10% ointment has to be

applied for six weeks.

The study will proceed according to standardized case report forms, describing which

aspects of the tumour should be examined at the moment of inclusion (inclusion visit), the

first control visit after 3 weeks, the second control visit after 6 weeks and the end visit before

excision in week 8. We planned surgical excision two weeks after the last application of the

study ointments in order to prevent surgical excision has to be postponed due to local

application-site reactions.

Tumour size, local tolerability, adverse events and concomitant medications will be recorded

at each control visit.

Therapeutic surgical excision of the target tumour will be performed two to three months after

diagnosis, for histological evaluation of response. The target tumour will be excised with a

3mm margin surrounding the tumour by different dermatologists at the MUMC+. After regular

histological examination of the resection margins, a histological evaluation of response will

be done by two independent dermatopathologists. Additional immunohistochemical stainings

on punch biopsy (baseline t=0) and excision specimens (t=1) will be done to assess other

histological effects of the treatment. Patients and investigators, including the assessing

pathologists, will be blinded until the end of the study.




4. STUDY POPULATION

4.1 Population (base)

Male and female outpatients, aged 18 years or older without serious comorbidities of the

Dermatology department of MUMC+, The Netherlands, with histological proven primary

superficial basal cell carcinoma ≥ 4mm and ≤ 20mm in diameter outside the H-zone of the

face will be informed about the study trough informed consent.

One sBCC per patient will be included to ensure independence of observations. For

patients with more than one sBCC, the most accessible for treatment and with the largest

size will be chosen.

Based on the pathological registration in 2009 in MUMC+, we expect an average of 30

new sBCC per month, so recruitment of the required number of patients (n=42, see 4.4

sample size calculation) is considered feasible.

4.2 Inclusion criteria

In order to be eligible to participate in this study, a subject must meet all of the following

criteria:

• Adults aged 18 years or older

• Primary histological proven superficial basal cell carcinoma between ≥ 4mm and ≤

20mm in diameter

• Comorbidities may not interfere with study treatment (evaluated by investigator)

• Capable to understand instructions

4.3 Exclusion criteria

A potential subject who meets any of the following criteria will be excluded from

participation in this study:

• Recurrent sBCC (previous treatment)

• Breast-feeding or pregnant women

• Serious comorbidities

• Use of immunosuppressive medication during

the trial period or within 30 days before

enrolment

• Patients with genetic skin cancer disorders

• Tumour located in the H zone (high-risk area

of face) or hairy scalp (see picture 1)

Picture 1. H-zone of the Face




4.4 Sample size calculation

It is assumed that about 5% of sBCCs in the placebo group will show histological complete

tumour regression according to the excision specimen, because of a possible biopsy-induced

tumour regression25. At least 50% in the sinecatechins 10% group has to show a complete

tumour regression to consider this treatment as sufficiently effective for further evaluation. A

tumour regression of at least 50% was based on expert opinion, as there is no available

clinical literature of topical sinecatechins for the treatment of sBCC yet. Based on this opinion

a tumour regression in less than 50% of the patients was not found sufficient to conduct

further clinical trials. Based on an alpha=5%, and power of 80%, a total of 38 patients (19

patients per group) are required. This sample size was based on per-protocol analysis and

measured with Fleiss continuity correction method in the following formula:

.

To account for a loss-to-follow-up of 10%, a total of 42 patients (21 patients per group) will be

included.




5. TREATMENT OF SUBJECTS

5.1 Investigational product/treatment

Intervention:

• Sinecatechins (Veregen®)

• Ingredients: white petrolatum, cera alba (white wax), isopropyl myristate, oleyl

alcohol, propylene glycol monopalmitostearate.

• Active ingredient: Tea polyphenols, particularly catechins (more than 85%). 1g of the

ointment contains 100mg of polyphenon E extract (as dry extract), refined from

Camellia sinensis (L.)O. Kuntze folium (green tea leaf), corresponding to 55-72mg of

(-)-epigallocatechin gallate. 26

• Strength: 10%

• Dosage form: ointment. Brown smooth ointment free from gritty particles.

• Manufacturer: MediGene AG/ Apotheek Radboud UMC

• Marketing authorisation holder: WILL-PHARMA

Placebo:

• Ingredients: white petrolatum, cera alba (white wax), isopropyl myristate, oleyl

alcohol, propylene glycol monopalmitostearate.

• Dosage form: ointment

• Manufacturer: MediGene AG/ Apotheek Radboud UMC

• Marketing authorisation holder: WILL-PHARMA

After randomization, patients apply a thin layer of ointment on the tumour including 5mm

surrounding skin with no occlusive dressing applied. After application, patients are

advised to wash their hands to prevent spreading of the ointment. These actions should

be performed twice daily (morning and evening) for six weeks. Before applying a new

layer patients are advised to wipe off the remnants.

5.2 Use of co-intervention

Concomitant use of other topical treatments on the tumour area is prohibited during the

trial. The use of immunosuppressive medication during the trial or within 30 days before

enrolment is prohibited. Any other oral medication is only allowed after consulting the

principal investigator. Oral intake of green tea is prohibited during the trial or within one

week before enrolment, since in vivo testing of oral administration of green tea on rodents

susceptible on skin cancer showed a significant reduction of new skin tumours and tumour

size.27-29




Oral paracetamol 500-1000mg, if necessary, respectively every 4 or 6 hours could be

prescribed for local pain due to skin reactions. Topical treatments are not allowed. In case

of severe local skin reactions treatment could be temporarily stopped for a maximum of

one week.

5.3 Escape medication

After end of the study a surgical excision will be performed in intervention group and

placebo group.




6. INVESTIGATIONAL PRODUCT

6.1 Name and description of investigational products

• Sinecatechins 10% ointment (MediGene/WILL PHARMA)

• Placebo (MediGene/WILL PHARMA)

6.2 Summary of findings from non-clinical studies

The United States Food and Drug Administration has approved the topical ointment

sinecatechins for the treatment of external genital and perianal warts (condylomata

acuminata) in October 200630. The exact mechanism of action of sinecatechins in

eradication of human papillomavirus-induced condylomata acuminata is unknown but may

be due to catechins binding to a number of proteins leading to antioxidative, antiviral,

immunostimulatory and antiproliferative effects. In September 2012 sinecatechins 10%

ointment was registered for the treatment of condylomata acuminate in the Netherlands.

Cancer-preventive effects of EGCG are widely supported by results from epidemiological,

cell culture and animal studies.15,16

Singh et al. showed EGCG had a cytotoxic effect on skin cancer cells without incurring

significant cytotoxicity to normal skin cells under experimental conditions with human skin

cancer cell lines.17 They also suggested inactivation of β-catenin signalling in EGCG-

treated skin cancer cells.17 β-Catenin is an important component of the Wnt pathway.

Yang and colleagues proved that the wingless-type MMTV integration site family (WNT/β-

catenin) pathway is essential in tumorigenic response to deregulated SHH signalling,

confirming crosstalk between the SHH and Wnt pathways in BCCs.10

Meeran et al. showed that topical application of EGCG on wild-type mice resulted in a

significant reduction in UVB-induced skin tumorigenesis in terms of tumour incidence and

tumour multiplicity compared with non-EGCG-treated wild-type mice. This chemo

preventive effect was not observed in Il-12 KO mice treated with topical EGCG, which

suggests that the prevention of photo carcinogenesis by EGCG was mediated, at least in

part, through Il-12 dependent DNA repair.31,32

Mittal et al. also showed inhibition of UV-induced tumour incidence and tumour multiplicity

after topical application of EGCG (1mg/cm2) in hydrophilic cream in SKH-1 hairless mice.

Furthermore, the growth or size of tumours in the EGCG-treated group was significantly

inhibited when measured in terms of total tumour volume/group, tumour volume/tumour-

bearing mouse and average tumour volume/tumour compared to that of the non-EGCG-

treated group.33




Cyclooxygenase-2 (COX-2) is induced by a large spectrum of growth factors and pro-

inflammatory cytokines in specific pathophysiological circumstances. COX-2 is commonly

overexpressed BCCs, which in turn mediates the expression of PGE234. Katiyar et al.

found that EGCG pre-treated human skin exposed to UVB significantly reduced

prostaglandin metabolites, particularly PGE2.22 Tyring et al. showed an inhibitory effect of

sinecatechins (10µM and 50µM) on cyclooxygenase-1 (COX-1) and cyclooxygenase-2

(COX-2), with a slight selectivity of greater inhibition against COX-2.35

Numerous in vitro cell culture studies demonstrated inhibition of cell growth and induction

of apoptosis after treatment with EGCG in concentrations within the range 1-100µM.18-21,36

It is suggested that EGCG inhibits the anti-apoptotic function of Bcl-2 proteins.15

Another possible mechanism by EGCG exercise their anti-tumour property is through the

suppression of the NFκB signalling pathway. NFκB is activated by different stimuli e.g.

inflammatory stimuli, carcinogens and tumourpromotors and induces the expression of

more many genes that suppress apoptosis and induce proliferation and inflammation.15

6.3 Summary of findings from clinical studies

Limited data are currently available from EGCG chemoprevention clinical trials. Several

clinical phase II and III trials showed that the use of topical sinecatechins in treatment of

condylomata acuminata is effective and safe.23,24,37

In two double-blind, multinational randomized controlled trials in adults with external

genital and perianal warts, sinecatechins 10% and 15% ointment (Veregen®), three times

daily for up to 16 weeks was generally well tolerated.23,24 According to pooled data

(n=1005) from the two clinical studies, the majority of adverse events associated with

polyphenon E 10% ointment involved application site and local skin reactions at the

treatment site. The maximum incidence was reached after 4 weeks of treatment in the

sinecatechins 10% group and after two weeks in de sinecatechins 15% group.38 Rates

then decreased gradually until the end of treatment. The most common severe local

reactions were erythema, pruritus, irritation and pain and were reported by 25.8% of the

patients in the sinecatechins 10% group and by 27% of the patients in the sinecatechins

15% group (percentages based on number of patients with no missing data).38 According

to a logistical regression analysis, the complete clearance of all warts was significantly

associated with erosion/ulceration (OR 1.87 [95% CI 1.36, 2.57]) and erythema (OR 1.61

[95% CI 1.16, 2.24]), suggesting that patients who experienced at least one of these

adverse events had a higher likelihood of achieving complete clearance.38

Summarized, both non-clinical and clinical studies show that topical application of

sinecatechins ointment will be safe with only local side-effects and has a potential




anticarcinogenic effect in BCCs. Further information on the ointment can be found in the

SPC document/IB (Annex D2/D1)26.

6.4 Summary of known and potential risks and benefits

A potential risk for patients in this study is an allergy for one of the components of the

ointment. Sinecatechins 10% and placebo contain propylene glycol monopalmitostearate

which may cause skin irritations and isopropyl myristate which may cause irritation and

sensitization of the skin.26 Application site and local skin reactions (erythema, pruritus,

irritation, pain, erosion/ulceration) and infections may occur. We do not expect any other

risks.

Considering the regular two to three months waiting time for a surgical excision and the

fact that BCCs tend to grow very slowly1, eight weeks is an acceptable period for subjects

to wait for their standard surgical treatment.

6.5 Description and justification of route of administration and dosage

Basal cell carcinoma is the most frequent malignant tumour in Caucasians. This type of

skin cancer rarely metastasizes, but without adequate treatment it will be locally invasive1.

We hypothesize that topical application of sinecatechins results in a higher concentration

at the target tumour in comparison with oral administration. Since sBCCs grow down from

the epidermis into the superficial dermis they are easily accessible for topical treatment.

The available topical treatments imiquimod and 5-fluorouracil cream result in local tumour

destruction by apoptosis, necrosis or stimulation of the immune system. As mentioned

above, the active ingredient (EGCG) in sinecatechins 10% ointment is thought to have a

cytotoxic effect on skin cancer cells and has the availability of inhibition of cell growth and

induction of apoptosis. Next, there is also evidence that EGCG plays a role on the WNT

signalling pathway, activated in BCC and on COX-2, highly expressed in BCC. As EGCG

targets tumour cells in different ways, we hypothesize that application twice daily for 6

weeks will be a reasonable treatment regimen as this is conform the other available

topical self-applicable treatments (imiquimod and 5-fluorouracil) for sBCC.7,39

6.6 Dosages, dosage modifications and method of administration

Patients are instructed to apply a thin layer of the sinecatechins 10% or placebo ointment

twice daily (morning and evening) in a thin layer to the tumour including 5mm of the

surrounding skin. Sinecatechins 10% ointment has to be applied for six weeks. Patients

are advised to wash their hands after each application to prevent spreading of the

ointment.

6.7 Preparation and labelling of Investigational Medicinal Product

Sinecatechins 10% ointment and placebo will be sponsored by WILL PHARMA and

delivered to the MUMC pharmacy. The tubes will be labelled according to the relevant




GMP guidelines with a preassigned patient number by Apotheek Radboud UMC,

Nijmegen, The Netherlands. Placebo will be of identical colour and consistency as

sinecatechins 10% ointment to ensure blinding. Tubes will be stored under 25 degrees.

6.8 Drug accountability

Tubes will be picked up at the day of inclusion for each patient at the MUMC pharmacy by

the investigator. After randomisation according to the randomisation list, subjects will

receive their tubes by the investigator immediately at their inclusion visit at the

dermatology outpatient clinic at the MUMC. Treatment can start directly and therefore we

can guarantee patients will receive their medication on time. At the end of the study,

subjects are instructed to take the tube to their control visit at week 6. Tubes will be

collected and weighted by the investigator to assess compliance.




7. NON-INVESTIGATIONAL PRODUCT

7.1 Name and description of non-investigational product(s)

Not applicable.

7.2 Summary of findings from non-clinical studies

Not applicable.

7.3 Summary of findings from clinical studies

Not applicable.

7.4 Summary of known and potential risks and benefits

Not applicable.

7.5 Description and justification of route of administration and dosage

Not applicable.

7.6 Dosages, dosage modifications and method of administration

Not applicable.

7.7 Preparation and labelling of Non Investigational Medicinal Product

Not applicable.

7.8 Drug accountability

Not applicable.




8. METHODS

8.1 Study parameters/endpoints

8.1.1 Main study parameter/endpoint

The main study parameter is presence or absence of histological regression of the

target tumour according to the excision specimen. This will be assessed by two

independent dermato-pathologists who are blinded to treatment assignment.

8.1.2 Secondary study parameters/endpoints

• Compliance

Data for compliance with the prescribed regimens of either sinecatechins ointment

or placebo will be obtained from a personal diary kept by patients and completed

once a week during treatment. Compliance will be calculated as the number of

applications actually applied by the patient divided by the total prescribed number of

applications. Furthermore tubes will be collected and weighted by the investigator.

• Number of local skin reactions, adverse events and serious adverse events

Local skin reactions at application site represent a special safety issue for topically

applied treatments. Therefore we will evaluate and describe local skin reactions

separately from other adverse events.

At inclusion visit, after punch biopsy (t=0), control visit in week 3, control visit in

week 6 and end visit in week 8 before excision (t=1), tumour size, colour and

objective local skin reactions (ie. Erythema, edema, induration, vesicles,

erosion/ulceration, or other) will be assessed by the investigator.

The maximum incidence of local application site and local skin reactions at the

treatment site was reached after 4 weeks of treatment with topical sinecatechins

10% on condylomata acuminata in the review of Tatti et al. Therefore we scheduled

a first follow-up visit at week 3 to evaluate these local skin reactions and to ensure

continuation of treatment.

Subjective symptoms (ie. Pain, burning, itching, or other) will be assessed from the

personal diary kept by patients once a week during treatment.

Intensity of all skin reactions at the site of applications will be graded as: none, mild

(local skin reaction which can be easily tolerated), moderate (local skin reaction

which is associated with considerable discomfort, but does not prevent usual

activity) or severe (local skin reaction which substantially interferes with the patients’

usual activity).




Adverse events other than local skin reactions at the application site reported by the

patient will be assessed according to the same grading.

Other adverse events or (suspected) (unexpected) serious adverse events will be

recorded by the investigator.

• Histological effects of intervention on the target tumour area will be assessed with

additional immunohistochemic stains on both punch biopsy (t=0) and surgical

excision specimen (t=1); Bcl-2 (anti-apoptosis), Ki67 (proliferation). The mean

percentage of cells expressing the different antibodies will be analysed by

comparing the proportion of cells expressing antibodies in the intervention group to

placebo group.

The percentage will be assessed at a magnification of 40x (one high power field is

2mm2) by two independent, blinded pathologists using the following criteria:

o Assessment of total tumour area

o Staining pattern

o Percentage of positive stained cells will be estimated and will be ranked on

a semi-quantitive scale as follows:

0, <20%, 1+, 20-40%, 2+, 40-60%, 3+, 60-80%, 4+, >80%

8.1.3 Other study parameters

Baseline characteristics (ie. age, sex, amount of sun-exposure, size and localisation

of the target tumour, medical history and concomitant medication) will be recorded.

8.2 Randomisation, blinding and treatment allocation

Patients will be randomized to either intervention or placebo according to a generated

randomization list using random permuted blocks of four. An independent statistician

will prepare the randomization list. The randomization list will not be available to

investigators or the project team. The tubes will be labelled with a preassigned patient

number according to the randomization list, with each patient allocated to the lowest

available number. Patients and investigators, including the assessing pathologists,

will be blinded to treatment assignment until the end of the study. Placebo will be of

identical colour and consistency as sinecatechins ointment to ensure blinding.

Indications for unblinding are serious suspected adverse events or suspected

unexpected serious adverse events. Only the coordinating investigator is allowed to

break the randomisation code. In all other situations unblinding will take place after




allocating participants to the relevant analyses populations, just before the primary

statistical analysis.

8.3 Study procedures

First visit:

• Description of tumour by treating doctor: size, colour, dermatological description,

localisation

• Standardized photographs

• Punch biopsy (3mm) of suspect superficial basal cell carcinoma

• Short oral and written information of the study by the outpatient clinic physician

and explanation of phone consultation by the coordination investigator.

After confirmation of the diagnosis of a superficial basal cell carcinoma, patient will

get a phone consultation by the coordinating investigator and receive short

information about the study. If interested written information will be sent by mail and

an appointment will be made within one to two weeks.

Second (inclusion) visit (baseline) t=0:

• Description of tumour by investigator: size, colour, dermatological description,

localisation

• Detailed explanation of the study procedures

• In- or exclusion, in case of inclusion:

o Description of tumour: size, colour, dermatological description, localisation.

The tumour site and appropriate anatomic landmarks will be

mapped using a clear plastic sheet as a template to guide the excision at

the end of the study

o Baseline characteristics

o Standardized photographs with ruler and colour reference chart

o Randomization of the patient into intervention or placebo

o Distribution of study medication according to randomization

o Instruction of patient (see Annex E4.1.)

Third (control) visit (week 3):

• Description of tumour by investigator: size, colour, dermatological description, local

skin reactions

• Adverse events or serious adverse events

• Any change in baseline characteristics

• Standardized photographs with ruler and colour reference chart




Fourth (control) visit (week 6):


skin reactions




• Investigator will collect and weight the study medication to ensure compliance

Fifth (end) visit (week 8) (t=1):


skin reactions




• Surgical excision with a standard 3mm margin

• Investigator will receive patients diary

First visit, punch biopsy, telephonic consultation and surgical excision are part of

regular care of superficial basal cell carcinoma. Treatment with sinecatechins

ointment or placebo, inclusion visit and two control visits are part of the study.

All tissue samples will be formalin-fixed and paraffin-embedded (FFPE). As part of

regular care, 4µm sections will be stained with haematoxylin & eosin (H&E) to confirm

histological diagnosis and tumour regression in case of excision.

All tissues will follow the same protocol to improve the reliability of the staining

assessment. For each antibody, tissues known to have strong expression of the

respective protein will be included as a positive control. Negative controls, in which

the primary antibody was not added, will be included in all experiments.

8.4 Withdrawal of individual subjects

Subjects can leave the study at any time for any reason if they wish to do so without

any consequences. The investigator can decide to withdraw a subject from the study

for urgent medical reasons.

8.4.1 Specific criteria for withdrawal (if applicable)

Not applicable

8.5 Replacement of individual subjects after withdrawal

After withdrawal of a subject we will not replace the subject by a new subject.




8.6 Follow-up of subjects withdrawn from treatment

Subjects withdrawn from therapy will be followed till surgical excision.

8.7 Premature termination of the study

The study will only be terminated if many patients experience suspected unexpected

serious adverse events or serious adverse events. In case the study will be

terminated prematurely the coordinating investigator will inform the METC within 15

days. Since clinical studies with sinecatechins ointment show it is safe in use, with

minimal serious adverse events we don’t expect premature determination to occur.




9. SAFETY REPORTING

9.1 Section 10 WMO event

In accordance to section 10, subsection 1, of the WMO, the investigator will inform the

subjects and the reviewing accredited METC if anything occurs, on the basis of which it

appears that the disadvantages of participation may be significantly greater than was

foreseen in the research proposal. The study will be suspended pending further review by

the accredited METC, except insofar as suspension would jeopardise the subjects’

health. The investigator will take care that all subjects are kept informed.

9.2 AEs, SAEs and SUSARs

9.2.1 Adverse events (AEs)

Adverse events are defined as any undesirable experience occurring to a subject

during the study, whether or not considered related to [the investigational product /

the experimental intervention]. All adverse events reported spontaneously by the

subject or observed by the investigator or his staff will be recorded.

9.2.2 Serious adverse events (SAEs)

A serious adverse event is any untoward medical occurrence or effect that at any

dose:

- results in death;

- is life threatening (at the time of the event);

- requires hospitalisation or prolongation of existing inpatients’ hospitalisation;

- results in persistent or significant disability or incapacity;

- is a congenital anomaly or birth defect;

- Any other important medical event that may not result in death, be life threatening,

or require hospitalization, may be considered a serious adverse experience when,

based upon appropriate medical judgement, the event may jeopardize the subject

or may require an intervention to prevent one of the outcomes listed above.

The sponsor will report the SAEs through the web portal ToetsingOnline to the

accredited METC that approved the protocol, within 15 days after the sponsor has

first knowledge of the serious adverse events.




SAEs that result in death or are life threatening should be reported expedited. The

expedited reporting will occur not later than 7 days after the responsible investigator

has first knowledge of the adverse event. This is for a preliminary report with another

8 days for completion of the report.

9.2.3 Suspected unexpected serious adverse reactions (SUSARs)

Adverse reactions are all untoward and unintended responses to an investigational

product related to any dose administered.

Unexpected adverse reactions are SUSARs if the following three conditions are met:

1. the event must be serious (see chapter 9.2.2);

2. there must be a certain degree of probability that the event is a harmful and an

undesirable reaction to the medicinal product under investigation, regardless of

the administered dose;

3. the adverse reaction must be unexpected, that is to say, the nature and severity

of the adverse reaction are not in agreement with the product information as

recorded in:

- Summary of Product Characteristics (SPC) for an authorised medicinal

product;

- Investigator’s Brochure for an unauthorised medicinal product.

The sponsor will report expedited the following SUSARs through the web portal

ToetsingOnline to the METC:

SUSARs that have arisen in the clinical trial that was assessed by the METC;

SUSARs that have arisen in other clinical trials of the same sponsor and with the

same medicinal product, and that could have consequences for the safety of the

subjects involved in the clinical trial that was assessed by the METC.

The remaining SUSARs are recorded in an overview list (line-listing) that will be

submitted once every half year to the METC. This line-listing provides an overview

of all SUSARs from the study medicine, accompanied by a brief report highlighting

the main points of concern.

The expedited reporting of SUSARs through the web portal ToetsingOnline is

sufficient as notification to the competent authority.

The sponsor will report expedited all SUSARs to the competent authorities in other

Member States, according to the requirements of the Member States.




The expedited reporting will occur not later than 15 days after the sponsor has first

knowledge of the adverse reactions. For fatal or life threatening cases the term will

be maximal 7 days for a preliminary report with another 8 days for completion of the

report.

Indications for unblinding are serious suspected adverse events or suspected

unexpected serious adverse events. Only the coordinating investigator is allowed to

break the randomisation code.

9.3 Annual safety report

In addition to the expedited reporting of SUSARs, the sponsor will submit, once a year

throughout the clinical trial, a safety report to the accredited METC, competent authority,

and competent authorities of the concerned Member States.

This safety report consists of:

a list of all suspected (unexpected or expected) serious adverse reactions, along with

an aggregated summary table of all reported serious adverse reactions, ordered by

organ system, per study;

a report concerning the safety of the subjects, consisting of a complete safety analysis

and an evaluation of the balance between the efficacy and the harmfulness of the

medicine under investigation.

9.4 Follow-up of adverse events

All AEs will be followed until they have abated, or until a stable situation has been

reached. Depending on the event, follow up may require additional tests or medical

procedures as indicated, and/or referral to the general physician or a medical specialist.

SAEs need to be reported till end of study within the Netherlands, as defined in the

protocol

9.5 [Data Safety Monitoring Board (DSMB) / Safety Committee]

Not applicable.




10. STATISTICAL ANALYSIS

10.1 Primary study parameter(s)

Primary study outcome is histological regression of the target tumour on the excision

specimen as assessed by two independent dermatopathologists. Any discrepancy will be

resolved by consensus. The proportions of patients with complete histological regression

in the treatment group and placebo group will be compared and tested for statistical

significance using the Chi-square test. Both an intention-to-treat and per protocol analysis

will be performed. Missing data will be documented and patients loss-to-follow-up will be

analysed in the intention-to-treat-analysis. Reported P values will be two-sided and P

values ≤ 0.05 are considered statistically significant. Statistical analysis will be performed

by using SPSS version 20.0 software.

10.2 Secondary study parameter(s)

Compliance will be calculated as the number of applications actually applied by the

patient divided by the total prescribed number of applications. This ratio will be multiplied

by 100 to calculate compliance percentages. Mean compliance percentages will be

compared between the randomized groups and will be tested for significance using the t-

test for independent samples (if normally distributed) or the Mann-Whitney U test (if not

normally distributed).

Proportions of patients with local skin reactions and adverse events will be compared

between randomized groups and will be tested for statistical significance using the Chi-

square test.

For all outcome parameters, both an intention-to-treat and per protocol analysis will be

performed. Missing data will be documented and patients loss-to-follow-up will be

analysed in the intention-to-treat-analysis. Reported P values will be two-sided and P

values ≤ 0.05 are considered statistically significant. Statistical analysis will be performed

by using SPSS version 20.0 software.

10.3 Other study parameters

Baseline characteristics will be presented to enable assessment of comparability between

the intervention and placebo group. Nominal and categorical variables will be presented

as proportions and absolute number and continuous variables as mean ± standard

deviation (SD) or median and range.




10.4 Interim analysis (if applicable)

We do not plan to perform an interim analysis since topical sinecatechins 10% ointment is

a well-known safe drug and the intervention period is only six weeks.




11. ETHICAL CONSIDERATIONS

11.1 Regulation statement

The study will be conducted according to the principles of the Declaration of Helsinki

version 10 October 2013 and in accordance with the Medical Research Involving Human

Subjects Act (WMO).

11.2 Recruitment and consent

At patients first visit at the Dermatology department the outpatient clinic physician will

give short oral and written information of the study and explains the phone consultation

will be done by the coordinating investigator. When diagnosis of superficial basal cell

carcinoma is histologically confirmed by punch biopsy, the patient gets a phone

consultation with the coordinating investigator and is shortly informed about the study. If

interested, the patient will receive additional written patient information by mail. Patients

will get a consideration period of at least 1 week in which they can decide to participate or

not, followed by an appointment with the coordinating investigator. During consideration

period patients can contact the investigator/ independent physician with any question.

At the second (inclusion) visit, patients will be further informed about the study and if

willing to participate, they will sign informed consent at the same time with the

investigator. A copy of the signed subject informed consent form shall be given to each

study patient. The signed subject informed consent forms will be kept at the

investigational site on a secure location.

For the patient information letter see Annex E1 and for the informed consent form see

Annex E2.

11.3 Objection by minors or incapacitated subjects

Not applicable.

11.4 Benefits and risks assessment, group relatedness

Participation requires patients to apply the supplied ointment (sinecatechins 10% or

placebo) twice daily for six weeks. Participation in the study will take two times 5 minutes

a day. The first and fifth visit at the hospital are regular visits, even patients not

participating in the study should visit at the hospital at these moments. The second

(inclusion) and third and fourth (control) visits will be extra study visits for study patients.

As described above, a potential risk when participating in this study is an allergy for one




of the components of the sinecatechins 10% ointment or placebo. Furthermore, local skin

reactions due to the ointment are possible but can be easily controlled.

To confirm diagnosis, a 3mm punch biopsy is taken after injection of local anaesthetic

which is briefly painful. Patients not included in the study will also have a punch biopsy as

part of regular care. Subsequently, the tumour will be regularly excised in total after eight

weeks.

11.5 Compensation for injury

The sponsor/investigator has a liability insurance which is in accordance with article 7,

subsection 6 of the WMO.

The sponsor (also) has an insurance which is in accordance with the legal requirements

in the Netherlands (Article 7 WMO and the Measure regarding Compulsory Insurance for

Clinical Research in Humans of 23th June 2003). This insurance provides cover for

damage to research subjects through injury or death caused by the study.

1. € 450.000,-- (i.e. four hundred and fifty thousand Euro) for death or injury for each

subject who participates in the Research;

2. € 3.500.000,-- (i.e. three million five hundred thousand Euro) for death or injury for

all subjects who participate in the Research;

3. € 5.000.000,-- (i.e. five million Euro) for the total damage incurred by the

organisation for all damage disclosed by scientific research for the Sponsor as

‘verrichter’ in the meaning of said Act in each year of insurance coverage.

The insurance applies to the damage that becomes apparent during the study or within 4

years after the end of the study.

For further information see the insurance text: Annex G1.

11.6 Incentives

Patients will receive a refund of the travel expenses.




12. ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION

12.1 Handling and storage of data and documents

Patient data are stored in a protected computer file and will be processed anonymously. A

subject identification code list is used to link the data to the subject. Coding is not based

on patients initials or birth-date. Patient material will be coded in the same way. The key to

the data and patient material code both will be safeguarded by the pharmacist.

All data, photographs and slides for the immunohistochemical stains Ki-67 en Bcl-2 will

be stored for a maximum of 15 years after the end of the trial for further future research.

Punch biopsy and excision specimens will be stored at the Pathology Department as part

of clinical routine. During and after the study, the coordinating and principal investigators

will have access to patient material and data. Patients will be informed and asked for their

permission for further future analysis in the informed consent form (Annex E2). Future

analysis with punch biopsy and excision specimens will be performed only if patients and

the medical ethics committee gave their permission.

12.2 Monitoring and Quality Assurance

Monitoring will be performed by the Clinical Trial Centre Maastricht and will be based on

the risk classification. The degree of monitoring will depend on this classification.

12.3 Amendments

A ‘substantial amendment’ is defined as an amendment to the terms of the METC

application, or to the protocol or any other supporting documentation, that is likely to

affect to a significant degree:

- the safety or physical or mental integrity of the subjects of the trial;

- the scientific value of the trial;

- the conduct or management of the trial; or

- the quality or safety of any intervention used in the trial.

All substantial amendments will be notified to the METC and to the competent authority.

Non-substantial amendments will not be notified to the accredited METC and the

competent authority, but will be recorded and filed by the sponsor.




12.4 Annual progress report

The sponsor/investigator will submit a summary of the progress of the trial to the

accredited METC once a year. Information will be provided on the date of inclusion of the

first subject, numbers of subjects included and numbers of subjects that have completed

the trial, serious adverse events/ serious adverse reactions, other problems, and

amendments.

12.5 End of study report

The sponsor will notify the accredited METC and the competent authority of the end of

the study within a period of 90 days. The end of the study is defined as the last patient’s

last visit.

In case the study is ended prematurely, the sponsor will notify the accredited METC and

the competent authority within 15 days, including the reasons for the premature

termination.

Within one year after the end of the study, the investigator/sponsor will submit a final

study report with the results of the study, including any publications/abstracts of the study,

to the accredited METC and the Competent Authority.

12.6 Public disclosure and publication policy

There are no limitations with regard to publication of the results of the study. The findings

will be published in international peer-reviewed open access journals and will be

communicated in (inter)national conferences to scientists/physicians. In exceptional

cases, if the public interest requires, we will spread results via popular media.




13. STRUCTURED RISK ANALYSIS

13.1 Potential issues of concern

a. Level of knowledge about mechanism of action

There are numerous epidemiological, cell culture and animal studies about the possible

effects of EGCG, the major catechin in sinecatechins ointment, on skin cancer.

Possible mechanisms of sinecatechins ointment on superficial basal cell carcinoma are

described in chapter 6.2 of this protocol and include inhibition of cell growth and induction

of apoptosis18-21,37, inactivation of β-catenin signalling17, prevention of

photocarcinogenesis31,32, at least in part, through Il-12 dependent DNA repair and an

inhibitory effect on cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2), with a

slight selectivity of greater inhibition against COX-235.

b. Previous exposure of human beings with the test product(s) and/or products with a

similar biological mechanism

Previous exposure of human beings with the test products is described in several

studies.23,24 The exact mechanism of action of sinecatechins in eradication of human

papillomavirus-induced condylomata acuminata is unknown but may be due to catechins

binding to a number of proteins leading to antioxidative, antiviral, immunostimulatory and

antiproliferative effects.

Topical application of sinecatechins 10% ointment on sBCC in human beings was never

tested.

c. Can the primary or secondary mechanism be induced in animals and/or in ex-vivo

human cell material?

Since most human BCC arise due to PTCH mutations, PTCH mutant mice certainly

represent the closest model to the human condition.40 PTCH+/- mice (mice lacking one

patched gene) might be a valuable tool to analyze efficacy of new anti-BCC drugs,

however due to the mode of BCC induction by exposure to ionizing radiation (IR) or

ultraviolet radiation (UV), the molecular mechanisms responsible for BCC formation are

probably very heterogeneous.40 IR or UV radiation in PTCH+/- mice results in nodular,

superficial as well as infiltrative BCC subtypes, trichoblastomas and also squamous cell

carcinoma (SCC), a more aggressive form of skin cancer with a potential to metastasize.40

Because UV or IR radiation in mice results in different BCC subtypes or other forms of

skin cancer, this inhibits investigation of topical sinecatechins 10% ointment on sBCC

subtypes specifically. There are no human ex-vivo tests specific for skin with sBCC

treated with topical application of sinecatechins 10% during 6 weeks available.

d. Selectivity of the mechanism to target tissue in animals and/or human beings

Singh et al. showed EGCG had a cytotoxic effect on skin cancer cells without incurring

significant cytotoxicity to normal skin cells under experimental conditions with human skin

cancer cell lines.17




e. Analysis of potential effect

“Preclinical safety data were gained with the extract from green tea leaves or the higher

strength Veregen 15% ointment. No special hazard for humans was revealed concerning

safety pharmacology, genotoxicity and carcinogenic potential (herbal preparation). In

conventional studies of repeated dose toxicity, no effects beside the local effects could be

seen using the Veregen 15% ointment. Results are fully applicable for the lower strength

Veregen 10% ointment”.26 See SPC/IB document (Annex D2/D1).

In two double-blind, multinational randomized controlled trials in adults with external

genital and perianal warts, sinecatechins 10% and 15% ointment (Veregen®), three times

daily for up to 16 weeks was generally well tolerated with only local side-effects.23,24

f. Pharmacokinetic considerations

The pharmacokinetics of topically applied extract from green tea leaves have not been

sufficiently characterized.26

g. Study population

Male and female outpatients, aged 18 years or older of the dermatology department of the

MUMC+, The Netherlands, with histological proven primary superficial basal cell

carcinoma ≥ 4mm < 20mm outside the H zone of the face or hairy scalp will be informed

about the study trough informed consent. Breast-feeding or pregnant women, patients

using immunosuppressive medication during the trial period or within 30 days before

enrolment, with genetic skin cancer disorders or with a tumour located in the H zone

(high-risk area of face) or hairy scalp are excluded from study.

h. Interaction with other products

Since sinecatechins 10% ointment is applied topically and concomitant use of other

topical treatments on the tumour area and the use of immunosuppressive medication

during the trial or within 30 days before enrolment is prohibited we do not expect potential

pharmacokinetic interactions.

i. Predictability of effect

Topical sinecatechins 10% ointment on sBCC in human subjects was never tested before.

Potential biomarkers for effect of topical sinecatechins 10% in human are Ki67, a

proliferation marker and Bcl-2, an anti-apoptosis marker. These additionally

immunohistochemic stains will be used to show anti-proliferative and pro-apoptotic effects

of sinecatechins 10% ointment on sBCC. The immunohistochemic stains will be analyzed

by two independent dermato-pathologists by comparing the proportion of cells expressing

antibodies in the intervention group to placebo group.

j. Can effects be managed?




Oral paracetamol 500-1000mg, if necessary, respectively every 4 or 6 hours could be

prescribed for pain due to local skin reactions. In case of severe local skin reactions

treatment could be temporarily stopped for a maximum of one week.

13.2 Synthesis

Male and female outpatients, aged 18 years or older without serious comorbidities with a

primary sBCC ≥4mm and <20mm outside the H zone of the face are included. This

subtype of BCC is a low risk BCC and has an extremely low risk to metastasize. As

described above, a potential risk when participating in this study is an allergy for one of

the components of the sinecatechins 10% ointment or placebo.

Local skin reactions at application site represent a special safety issue for topically applied

treatments. Therefore we will evaluate and describe local skin reactions separately from

other adverse events. Local skin reactions can be easily controlled and therefore are

acceptable for the subjects. We do not expect any other risks.

14. REFERENCES

1. Roewert-Huber J, Lange-Asschenfeldt B, Stockfleth E, Kerl H. Epidemiology and aetiology of basal cell carcinoma. The British journal of dermatology 2007;157 Suppl 2:47-51. 2. Flohil SC, Seubring I, van Rossum MM, Coebergh JW, de Vries E, Nijsten T. Trends in Basal cell carcinoma incidence rates: a 37-year Dutch observational study. The Journal of investigative dermatology 2013;133:913-8. 3. Rippey JJ. Why classify basal cell carcinomas? Histopathology 1998;32:393-8. 4. Arits AH, Schlangen MH, Nelemans PJ, Kelleners-Smeets NW. Trends in the incidence of basal cell carcinoma by histopathological subtype. Journal of the European Academy of Dermatology and Venereology : JEADV 2011;25:565-9. 5. Scrivener Y, Grosshans E, Cribier B. Variations of basal cell carcinomas according to gender, age, location and histopathological subtype. The British journal of dermatology 2002;147:41-7. 6. Roozeboom MH, Arits AH, Nelemans PJ, Kelleners-Smeets NW. Overall treatment success after treatment of primary superficial basal cell carcinoma: a systematic review and meta-analysis of randomized and nonrandomized trials. The British journal of dermatology 2012;167:733-56. 7. Arits AH, Mosterd K, Essers BA, et al. Photodynamic therapy versus topical imiquimod versus topical fluorouracil for treatment of superficial basal-cell carcinoma: a single blind, non-inferiority, randomised controlled trial. The lancet oncology 2013;14:647-54. 8. Gallagher RP, Hill GB, Bajdik CD, et al. Sunlight exposure, pigmentary factors, and risk of nonmelanocytic skin cancer. I. Basal cell carcinoma. Archives of dermatology 1995;131:157-63. 9. Epstein EH. Basal cell carcinomas: attack of the hedgehog. Nature reviews Cancer 2008;8:743-54. 10. Yang SH, Andl T, Grachtchouk V, et al. Pathological responses to oncogenic Hedgehog signaling in skin are dependent on canonical Wnt/beta3-catenin signaling. Nature genetics 2008;40:1130-5. 11. Saldanha G, Ghura V, Potter L, Fletcher A. Nuclear beta-catenin in basal cell carcinoma correlates with increased proliferation. The British journal of dermatology 2004;151:157-64. 12. Mullor JL, Dahmane N, Sun T, Ruiz i Altaba A. Wnt signals are targets and mediators of Gli function. Current biology : CB 2001;11:769-73.




13. Barker N, Clevers H. Mining the Wnt pathway for cancer therapeutics. Nature reviews Drug discovery 2006;5:997-1014. 14. Reifenberger J, Wolter M, Knobbe CB, et al. Somatic mutations in the PTCH, SMOH, SUFUH and TP53 genes in sporadic basal cell carcinomas. The British journal of dermatology 2005;152:43-51. 15. Singh BN, Shankar S, Srivastava RK. Green tea catechin, epigallocatechin-3-gallate (EGCG): mechanisms, perspectives and clinical applications. Biochemical pharmacology 2011;82:1807-21. 16. Afaq F, Katiyar SK. Polyphenols: skin photoprotection and inhibition of photocarcinogenesis. Mini reviews in medicinal chemistry 2011;11:1200-15. 17. Singh T, Katiyar SK. Green tea polyphenol, (-)-epigallocatechin-3-gallate, induces toxicity in human skin cancer cells by targeting beta-catenin signaling. Toxicology and applied pharmacology 2013. 18. Yang GY, Liao J, Kim K, Yurkow EJ, Yang CS. Inhibition of growth and induction of apoptosis in human cancer cell lines by tea polyphenols. Carcinogenesis 1998;19:611-6. 19. Gupta S, Hastak K, Afaq F, Ahmad N, Mukhtar H. Essential role of caspases in epigallocatechin-3-gallate-mediated inhibition of nuclear factor kappa B and induction of apoptosis. Oncogene 2004;23:2507-22. 20. Tyring SK. Effect of Sinecatechins on HPV-Activated Cell Growth and Induction of Apoptosis. The Journal of clinical and aesthetic dermatology 2012;5:34-41. 21. Larsen CA, Dashwood RH, Bisson WH. Tea catechins as inhibitors of receptor tyrosine kinases: mechanistic insights and human relevance. Pharmacological research : the official journal of the Italian Pharmacological Society 2010;62:457-64. 22. Katiyar SK, Matsui MS, Elmets CA, Mukhtar H. Polyphenolic antioxidant (-)-epigallocatechin-3-gallate from green tea reduces UVB-induced inflammatory responses and infiltration of leukocytes in human skin. Photochemistry and photobiology 1999;69:148-53. 23. Tatti S, Swinehart JM, Thielert C, Tawfik H, Mescheder A, Beutner KR. Sinecatechins, a defined green tea extract, in the treatment of external anogenital warts: a randomized controlled trial. Obstetrics and gynecology 2008;111:1371-9. 24. Stockfleth E, Beti H, Orasan R, et al. Topical Polyphenon E in the treatment of external genital and perianal warts: a randomized controlled trial. The British journal of dermatology 2008;158:1329-38. 25. Swetter SM, Boldrick JC, Pierre P, Wong P, Egbert BM. Effects of biopsy-induced wound healing on residual basal cell and squamous cell carcinomas: rate of tumor regression in excisional specimens. Journal of cutaneous pathology 2003;30:139-46. 26. Summary of product characteristics: Veregen 10% ointment. 2012. at http://www.old.health.gov.il/units//pharmacy/trufot/alonim/VEREGEN_10_dr_1344321130396.pdf.) 27. Lou YR, Lu YP, Xie JG, Huang MT, Conney AH. Effects of oral administration of tea, decaffeinated tea, and caffeine on the formation and growth of tumors in high-risk SKH-1 mice previously treated with ultraviolet B light. Nutrition and cancer 1999;33:146-53. 28. Mantena SK, Meeran SM, Elmets CA, Katiyar SK. Orally administered green tea polyphenols prevent ultraviolet radiation-induced skin cancer in mice through activation of cytotoxic T cells and inhibition of angiogenesis in tumors. The Journal of nutrition 2005;135:2871-7. 29. Wang ZY, Huang MT, Ferraro T, et al. Inhibitory effect of green tea in the drinking water on tumorigenesis by ultraviolet light and 12-O-tetradecanoylphorbol-13-acetate in the skin of SKH-1 mice. Cancer research 1992;52:1162-70. 30. U.S. Food and Drug Administration CfDEaR. Approval letter VeregenTm Ointment NDA 21902. 2006. 31. Meeran SM, Mantena SK, Elmets CA, Katiyar SK. (-)-Epigallocatechin-3-gallate prevents photocarcinogenesis in mice through interleukin-12-dependent DNA repair. Cancer research 2006;66:5512-20. 32. Meeran SM, Akhtar S, Katiyar SK. Inhibition of UVB-induced skin tumor development by drinking green tea polyphenols is mediated through DNA repair and


http://www.old.health.gov.il/units/pharmacy/trufot/alonim/VEREGEN_10_dr_1344321130396.pdf.

http://www.old.health.gov.il/units/pharmacy/trufot/alonim/VEREGEN_10_dr_1344321130396.pdf.



subsequent inhibition of inflammation. The Journal of investigative dermatology 2009;129:1258-70. 33. Mittal A, Piyathilake C, Hara Y, Katiyar SK. Exceptionally high protection of photocarcinogenesis by topical application of (--)-epigallocatechin-3-gallate in hydrophilic cream in SKH-1 hairless mouse model: relationship to inhibition of UVB-induced global DNA hypomethylation. Neoplasia (New York, NY) 2003;5:555-65. 34. Muller-Decker K. Cyclooxygenase-dependent signaling is causally linked to non-melanoma skin carcinogenesis: pharmacological, genetic, and clinical evidence. Cancer metastasis reviews 2011;30:343-61. 35. Tyring SK. Sinecatechins: Effects on HPV-Induced Enzymes Involved in Inflammatory Mediator Generation. The Journal of clinical and aesthetic dermatology 2012;5:19-26. 36. Masuda M, Suzui M, Weinstein IB. Effects of epigallocatechin-3-gallate on growth, epidermal growth factor receptor signaling pathways, gene expression, and chemosensitivity in human head and neck squamous cell carcinoma cell lines. Clinical cancer research : an official journal of the American Association for Cancer Research 2001;7:4220-9. 37. Gross G, Meyer KG, Pres H, Thielert C, Tawfik H, Mescheder A. A randomized, double-blind, four-arm parallel-group, placebo-controlled Phase II/III study to investigate the clinical efficacy of two galenic formulations of Polyphenon E in the treatment of external genital warts. Journal of the European Academy of Dermatology and Venereology : JEADV 2007;21:1404-12. 38. Tatti S, Stockfleth E, Beutner KR, et al. Polyphenon E: a new treatment for external anogenital warts. The British journal of dermatology 2010;162:176-84. 39. Breuninger H, Sebastian G, Kortmann RD, Schwipper V, Werner J, Garbe C. [Brief guidelines: Basal cell carcinoma of the skin]. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG 2006;4:441-3. 40. Nitzki F, Becker M, Frommhold A, Schulz-Schaeffer W, Hahn H. Patched knockout mouse models of Basal cell carcinoma. Journal of skin cancer 2012;2012:907543.


topical sinecatechins ointment in treatment of primary ... · protocol title ‘topical...

Documents