Neoplasms

Skin and Connective Tissue Diseases

All Conditions

Breast Neoplasms

Breast Diseases

Skin Diseases

Hematinics

All Drugs and Chemicals

Liver Extracts

There is no other intervention, only clinical treatment.

Zhiyong YU, PhD

Fukai WANG, MM

YU Zhiyong, PhD

WANG Fukai, MM

RATIONALE: Studying samples of plasm by metabolomics-based approach from women with metastasis breast cancer may help doctors understand the biomarker of visceral metastasis.

PURPOSE: This clinical trial is studying the biomarker of visceral metastasis by metabolomics approach in metastasis breast cancer undergoing treatment.

Imaging evaluation of the effect of chemotherapy on patients with visceral metastases from breast cancer, metabolomics was used to analyze the changes of metabolites in plasma, and to find biomarkers that could reflect visceral metastasis and treatment effects. The purpose is to help clinicians predict whether patients have potential visceral metastases, evaluate the effects of visceral metastasis treatment, and reflect the patient's prognosis.

Patients with visceral metastases on imaging examinations received chemotherapy as planned, and blood samples were collected from patients before and during imaging assessments. Analysis of metabolites in plasma using ultra high performance liquid chromatography. Patient information were collected through medical record, including race, age, height and body mass index, menarche age, menstrual status, menopausal age (if applicable), tobacco and alcohol history, motherhood history, family history, etc.

Metabolomics Explores Biomarkers for Metastatic Breast Cancer

Clinical Study of Metabolomics-based Approach Explore Biomarkers for Metastatic Breast Cancer

To assess the changes of metabolites during the process of our observation, and to find out the relationship between metabolite(s) and therapeutic effect.

To observe the duration from the stable condition to progression of disease. Patients were followed up every six months in first five years, then followed up once a year.

To observe the duration from the stable condition to death. Patients were followed up every six months in first five years, then followed up once a year.

Shandong Cancer Hospital and Institute

Head of Breast surgery

Rare Diseases

Cholangiocarcinoma

Klatskin Tumor

Adenocarcinoma

Carcinoma

Neoplasms, Glandular and Epithelial

Neoplasms by Histologic Type

Bile Duct Cancer

Anti-Inflammatory Agents

ABC294640

Mark L Levitt, MD, PhD

Vered Katz Ben-Yair, MSc

This is an expanded access program (EAP) for eligible participants who do not qualify for participation in, or who are otherwise unable to access, the ongoing clinical trial ABC-108. This program is designed to provide access to ABC294640 (Yeliva ®) for treatment of cholangiocarcinoma (CCA) prior to approval by the local regulatory agency. Availability will depend on territory eligibility. Participating sites will be added as they apply for and are approved for the EAP. An oncologist must decide whether the potential benefit outweighs the risk of receiving an investigational therapy based on the individual patient's medical history and program eligibility criteria.

Expanded Access for the Treatment of Advanced Cholangiocarcinoma With ABC294640 (Yeliva ®)

Expanded Access to ABC-108, A Phase IIA Study of ABC294640 in the Treatment of Patients With Advanced,Unresectable Intra-hepatic, Perihilar and Extra-Hepatic Cholangiocarcinoma

RedHill Biopharma Limited

Symptoms and General Pathology

Facies

Keratosis, Actinic

Keratosis

Precancerous Conditions

AD17137 topical treatment

Placebo

A topical treatment applied twice daily for 4 weeks to induce disappearance of facial actinic keratosis (AK). First 4 weeks treatment (visit 1, 2 and 3 at 0,2 an 4 weeks) treated as a double blind parallel study. From weeks 4 to 7 (visit 3 to visit 4) all patients to be treated by the active component.

Evaluation of a Topical Treatment for Actinic Keratosis

Phase 2 Double-blind, Randomized, Placebo-controlled, Parallel Group, Multi-center Study

Assuta Hospital Systems

Blood and Lymph Conditions

Syndrome

Leukemia

Cytopenia

Preleukemia

Myelodysplastic Syndromes

Leukemia, Myelomonocytic, Chronic

Leukemia, Myelomonocytic, Juvenile

Hematologic Diseases

Bone Marrow Diseases

Leukemia, Myeloid

Myeloproliferative Disorders

Myelodysplastic-Myeloproliferative Diseases

Chronic Disease

Disease Attributes

Chronic Graft Versus Host Disease

Chronic Myelomonocytic Leukemia

Juvenile Myelomonocytic Leukemia

Chronic Myeloproliferative Disorders

Myelodysplastic/myeloproliferative Disease

Micronutrients

Vitamins

Ascorbic Acid

Trace Elements

Antioxidants

Protective Agents

Vitamin C

Vitamin C (ascorbic acid) 500 mg/capsule. Ingestion of 2 capsules (1000 mg) daily for 12 months.

Placebo capsule. Ingestion of 2 capsules daily for 12 months. Placebo will be prepared as capsules that look and taste identical to the vitamin C supplement capsules. The content of the placebo is lactose, potato starch, gelatin, magnesium stearate, and talc.

Monotherapy with oral vitamin C supplementation to elevate plasma vitamin C level to the upper end of the physiological range.

Vitamin C (ascorbic acid)

Kirsten Grønbæk, Professor

The primary purpose of this multi-centre, randomized, placebo-controlled, double-blind phase II study is to investigate if oral vitamin C may change the biology of low-risk myeloid malignancies; i.e., clonal cytopenia of undetermined significance (CCUS), low-risk myelodysplastic syndromes (MDS), and chronic myelomonocytic leukemia (CMML)-0/1 by reversing the epigenetic changes characteristic of these disease entities. The epigenetic regulator TET2 is the gene most often affected in CCUS. Preclinical studies have shown that active demethylation by the TET enzymes is dependent on vitamin C, and the investigators and collaborators have shown that plasma vitamin C levels are exceedingly low in hematological cancer patients but are easily corrected by oral vitamin C. This study is part of an array of EVITA studies aimed at clarifying whether the standard of care of patients with myeloid malignancies should be changed and oral vitamin C supplement added to the treatment recommendations.

BACKGROUND Recent investigations have shown that mutations in epigenetic regulators are common, both in the apparently normal hematopoiesis of the elderly and in patients (pts) with myeloid cancers. It was long anticipated that DNA methylation was a permanent silencing mark, but with the discovery of the ten eleven translocation (TET) enzymes it became clear that active demethylation occurs. The initial steps in this process are catalyzed by TET enzymes, which are, however, frequently mutated and methylated in hematological cancers. The Jumonji enzymes, which catalyze histone demethylation, are also aberrantly regulated in hematological cancers.

Vitamin C (VitC) was identified in the 1930'ies as the necessary micronutrient in the prevention of scurvy. Unlike plants and most animals, humans are unable to synthesize vitC from glucose due to lack of the required enzyme, L-gulonolactone oxidase. Therefore, vitC must be provided through the diet. Recent studies recognize vitC as an important cofactor for the Fe(II)- and 2-oxoglutarate dioxygenase family. These include the TET enzymes, which are involved in the conversion of 5-methylcytosine (5-mC) to its oxidized derivatives 5-hydroxymethylcytosine (5-hmC), 5-carboxyl cytosine (5-caC), and 5-formylcytosine (5-fC), and the Jumonji enzymes that are involved in histone demethylation. Accordingly, vitC may potentially play an important role in the regulation of DNA and histone demethylation. However, \> 80 percentage of hematological cancer pts were found to be severely vitC deficient. Interestingly, analyses of 20 participants included in the investigators' recently conducted randomized, placebo-controlled pilot study (NCT02877277) show that the level of vitC in MDS and CMML pts undergoing treatment with azacitidine, is easily elevated to the normal range by oral vitC supplement (unpublished data). When pts that were already taking vitC supplements were switched to placebo, the vitC levels quickly dropped below the normal range.

It has also been shown that the formation of 5-hmC and its derivatives may be compromised in healthy individuals and pts with TET mutations. However, since many of these mutations are heterozygous, and since the three TET enzymes (TET1, TET2, and TET3) may have some redundancy, restoration of vitC to physiological levels might have an impact on the level of 5-hmC/5-mC in individuals with TET mutant clonal hematopoiesis or hematological cancer.

Analyses of 5-hmC/5-mC levels in peripheral blood (PB) mononuclear cells (MNCs) from the participants in the pilot study also showed a clear trend toward increased 5-hmC in the vitC arm, however, after designing the trial the investigators realized that 5-hmC/5-mC levels are better measured in hematopoietic stem cells in the bone marrow (BM) where the levels are 10-20 fold higher. Thus, the pilot study will be followed-up with a randomized placebo-controlled trial of oral vitC in individuals with low-risk myeloid malignancies; i.e., CCUS or low-risk MDS/CMML, to investigate if oral vitC can change the biology of these disease entities and ultimately prevent progression.

Hypotheses:

1. The investigators and collaborators have previously shown that cancer pts are vitC deficient, and individuals with CCUS, which represents pre-MDS, might also be vitC deficient. The hypothesis is that this may lead to reduced levels of 5-hmC/5-mC in vivo in both cancer pts and individuals with CCUS
2. Elevating serum vitC levels to the normal range in CCUS and low-risk MDS/CMML pts by oral supplementation with vitC may

   * reduce the malignant clone,
   * increase the 5-hmC/5-mC ratio,
   * change the plasma cytokine profile towards a less inflammatory, less tumorigenic profile,
   * change gene expression

Aims:

To determine if restoring vitC to the normal range in CCUS and low-risk MDS/CMML pts can:

1. reduce the malignant clone,
2. increase the 5-hmC/5-mC ratio in CCUS and low-risk MDS/CMML pts
3. reduce accumulation of 5-mC at promoters/enhancers/long terminal repeats (LTRs), or at other regulatory genomic regions of tumor suppressors/methylated driver genes/genes involved in hematopoietic development,
4. upregulate the expression of these genes,
5. change the plasma cytokine profile,
6. alter intestinal permeability (measured by concentration of bacterial DNA in peripheral blood) and/or composition of gut microbiota,
7. entail any safety risks.

RESEARCH PLAN A total of 100 patients is planned for enrolment. Individuals with CCUS, low-risk MDS, or CMML-0 or -1 will be included from Rigshospitalet, Herlev University Hospital, Odense University Hospital, Aalborg University Hospital or Keck Hospital of University of Southern California between November 2017-December 2021.

The participants will enter block randomization with a ratio of 1:1; vitC 1000 mg/day p.o. versus placebo for one year.

Up to 30 healthy elderly volunteers are planned for enrolment. Amount and type of bacterial DNA in PB will be determined and serve as controls.

MATERIAL AND MEASUREMENTS PB: PB samples (45 mL) will be taken at study entry and every 3 months (or more if required according to physician's choice) during the first year.

Measurements include blood counts including differential count, levels of folic acid, vitamin B12, vitamin D, iron, ferritin, transferrin, transferrin saturation, plasma vitC levels, cytokines, and bacterial DNA content (referenced to bacterial DNA on patient's skin and in feces).

BM: BM samples (18 mL) will be taken at study entry, after 3 months, and after one year.

Levels of vitC and various cytokines will be measured. Mutations in genes frequently involved in myeloid cancer/clonal hematopoiesis, including epigenetic regulators, and variant allele frequencies (VAF) will be investigated by targeted next generation sequencing in sorted BM CD34+ cells (if available) or BM negative fraction of CD34+ sorting at study entry, after 3 months and after one year.

RNA sequencing and total 5-hmC/5-mC assessment will be performed on BM CD34+ hematopoietic stem cells.

Feces: Feces samples (9 mL) will be collected from a subset of patients at study entry, after 3 months, and after one year. Bacterial DNA will be extracted and sequenced.

RESEARCH BIOBANK A research biobank will be established at The Epi-/Genome Laboratory, Rigshospitalet / Biotech Research and Innovation Centre to store the biological samples from the participants. The research biobank is approved by the Regional Science Ethics Committee and the Danish Data Protection Agency in accordance with the Act on Processing of Personal Data (license no. H-16022249 and 04864/RH-2016-259, respectively). Cryopreserved separated MNCs from BM and PB will be stored in addition to granulocyte pellets and plasma. The date for closing the research biobank is 31-12-2030.

For correlative studies, biological samples will be sent to Van Andel Research Institute, Grand Rapids, US, and Imperial College, London, UK (external collaborators), for RNA sequencing and analyses of DNA methylation and hydroxymethylation, respectively. Biological samples will also be sent to Life Science Faculty, University of Copenhagen, and The National Veterinary Institute, Technical University of Denmark (external collaborators) for measurement of serum vitC concentrations and analyses of T cell responses, respectively.

METHODS VitC measurement: Ascorbate and total vitC, i.e., ascorbate + dehydroascorbic acid (the oxidized form of vitC; DHA), are quantified by high-performance liquid chromatography (HPLC) with coulometric detection; DHA is assessed by subtraction of ascorbate from total vitC. Uric acid is used as endogenous internal standard.

Cell sorting: Magnetic-activated cell sorting (MACS, using a EasySep device).

Total 5-hmC/5-mC measurement: Dot blot analysis of 5-hmC. 5-hmC/5-mC measurement by Mass Spectrometry.

Locus specific 5-hmC/5-mC measurement: "EPIC" 850 K BeadChips. 5-hmC/5-mC at selected sites will be measured by pyrosequencing.

Gene expression: Total RNA sequencing and reverse transcriptase-quantitative polymerase chain reaction.

Mutation detection: Targeted next generation sequencing of a panel of genes recurrently mutated in myeloid cancer as described.

STATISTICAL CONSIDERATIONS AND POWER CALCULATION This study is the first study to examine the effects of vitC as monotherapy on 5-hmC/5-mC levels in hematopoietic stem cells in humans in vivo. Therefore, it is not possible to perform a power calculation or a sample size calculation. The number of participants (n=100) is set as an estimate of the number needed to observe a potential significant difference between the groups (vitC vs. placebo) in the primary endpoint; median change in VAF of somatic mutations from baseline to 12 months.

Efficacy analyses are by intention-to-treat. Safety analyses include all participants who receive at least one dose of protocol therapy.

ETHICAL CONSIDERATIONS The study has been approved by the Regional Science Ethics Committee (H-16022249) and the Danish Data Protection Agency (04864/RH-2016-259).

All participants included in the project will be informed orally and in writing. Participation will only be accepted after written consent. Participants will be informed that they can at any time for any reason withdraw from the study without it affecting their treatment in the health care system.

Using the targeted DNA sequencing approach described, there is a small risk of detecting a germline mutation in the participants related to myeloid malignancy. The participants will be asked to state in the informed consent if they do not want to receive any further relevant health-related information that may appear during the project analyses. Unless the participant explicitly states that he or she does not want to be informed of any potential health-related random findings in the study, the participant will be informed and offered further investigations and genetic counseling at the local hospital in case of random findings.

Patient disadvantages, side effects, risks, and complications Blood sampling is associated with brief discomfort and/or pain. No significant risks are associated with the blood sampling. Local bleeding can occur, which in rare cases can cause discomfort and discoloration for a few days. Rarely, a blood sampling can cause vasovagal reaction leading to a brief loss of consciousness.

BM aspiration is associated with brief pain while the local anesthesia is given. Furthermore, many individuals experience an uncomfortable feeling in the nates and leg while the BM is aspirated. This lasts approximately 30 seconds. Finally, some tenderness can occur for a few days after the procedure. Possible complications to undergoing a BM investigation include bleeding and infection. However, the incidence of these complications is extremely low.

According to the Nordic Nutrition Recommendations there is no evidence that intake of vitC above 1000 mg/day are either carcinogenic or teratogenic. However, high intakes (\> 1000-2000 mg/day) may cause diarrhea and other gastrointestinal disturbances and susceptible individuals may experience kidney stone formation from increased oxalate formation. Since vitC is only given at physiological doses, it is anticipated that the study is safe and will provide no additional risk for the participants; an assumption that is supported by the experience from the pilot study.

Prospective, randomized, placebo-controlled trial.

Randomization performed by the independent provider of study medication (Glostrup Pharmacy).

Epigenetics, Vitamin C, and Abnormal Blood Cell Formation - Vitamin C in Patients With Low-Risk Myeloid Malignancies

Epigenetics, Vitamin C, and Abnormal Hematopoiesis - Role of Vitamin C in Epigenetic Regulation in Hematopoiesis Sub-Study on CCUS, Low-Risk MDS, and CMML-0/1

Median change from baseline to 12 months in mutant allele burden as measured by the variant allele frequency (VAF) and number of mutations in the vitC group vs. the placebo group.

Mean change from baseline to 3 months and 12 months in global 5-hmC/5-mC measured in hematopoietic stem cells is compared between the vitamin C group and the placebo group. In addition, the mean change from baseline in 5-hmC/5-mC at 12 months is compared between participants in the vitamin C arm with baseline plasma vitamin C level in the normal range vs. participants in the vitamin C arm with baseline plasma vitamin C level below the normal range.

Mean change from baseline to 12 months in 5-mC at promoters/enhancers/long terminal repeats, and other regulatory genomic regions of tumor suppressors/methylated driver genes/genes involved in hematopoietic development.

Mean change from baseline to 12 months in methylated histone H3 lysine at position 9 at promoters/enhancers/long terminal repeats, and other regulatory regions of tumor suppressors/methylated driver genes/genes involved in hematopoietic development.

Mean change from baseline to 12 months in plasma cytokine levels (e.g., IL-6, S100A9, etc.).

Mean change from baseline to 12 months in mRNA levels of tumor suppressor genes, oncogenes, epigenetic regulators, cytokines, and genes involved in hematopoietic development.

Mean change from baseline to 3 months in mRNA levels of tumor suppressor genes, oncogenes, epigenetic regulators, cytokines, and genes involved in hematopoietic development.

Number of serious adverse events and treatment-related adverse events as assessed by CTCAE v5.0. Adverse events, that are not considered serious or related to vitamin C intake, will not be recorded.

Percentage of participants with baseline plasma vitamin C level below the normal physiological range.

Change in intestinal permeability and gut microbiota (concentration of bacterial DNA in PB and adscription of bacteria by sequencing)

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Metabolomics Explores Biomarkers for Metastatic Breast Cancer	NCT04302415	Breast Cancer	There is no oth...	18 Years - 70 Years	Shandong Cancer Hospital and Institute
Expanded Access for the Treatment of Advanced Cholangiocarcinoma With ABC294640 (Yeliva ®)	NCT03414489	Cholangiocarcin... Cholangiocarcin... Cholangiocarcin... Cholangiocarcin... Cholangiocarcin...	ABC294640	18 Years -	RedHill Biopharma Limited
Evaluation of a Topical Treatment for Actinic Keratosis	NCT01921907	Actinic Keratos...	AD17137 topical... Placebo	30 Years - 90 Years	Assuta Hospital Systems
Epigenetics, Vitamin C, and Abnormal Blood Cell Formation - Vitamin C in Patients With Low-Risk Myeloid Malignancies	NCT03682029	Myelodysplastic... Chronic Myelomo... Cytopenia	Vitamin C (asco... Placebo	18 Years -	Rigshospitalet, Denmark
Epigenetics, Vitamin C, and Abnormal Blood Cell Formation - Vitamin C in Patients With Low-Risk Myeloid Malignancies	NCT03682029	Myelodysplastic... Chronic Myelomo... Cytopenia	Vitamin C (asco... Placebo	18 Years -	Rigshospitalet, Denmark
Epigenetics, Vitamin C, and Abnormal Blood Cell Formation - Vitamin C in Patients With Low-Risk Myeloid Malignancies	NCT03682029	Myelodysplastic... Chronic Myelomo... Cytopenia	Vitamin C (asco... Placebo	18 Years -	Rigshospitalet, Denmark
Expanded Access for the Treatment of Advanced Cholangiocarcinoma With ABC294640 (Yeliva ®)	NCT03414489	Cholangiocarcin... Cholangiocarcin... Cholangiocarcin... Cholangiocarcin... Cholangiocarcin...	ABC294640	18 Years -	RedHill Biopharma Limited

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