PDT Plus Vitamin D3 for Anal Dysplasia

This is a phase I dose escalation study of photodynamic therapy (PDT) for the treatment of patients with pre-malignant tumors and superficial microinvasive disease of the anal canal and/or perianal skin. All subjects (a maximum of 12) will be given the photosensitizer ALA orally followed by the administration of red light (629-635 nm) to the tumor from a laser. The dose of ALA will be 40 mg/kg administered approximately 4-6 hours before light administration. There will be two levels of light dose: 50 and 100 J/cm2, 3-6 patients in each. Vitamin D3 (cholecalciferol) supplementation (10,000 IU daily) will be provided from 3 days prior through 14 weeks after light delivery for PDT. Patients will be observed for 30 days for the development of DLT. Patients will be followed up for 24 months for additional toxicity and efficacy data collection.

Inclusion criteria

• A histological or cytological diagnosis of high-grade dysplasia or carcinoma in-situ, within past 4 months.
• Premalignant lesions containing focal microinvasion are eligible when:

• Surgery is not clinically mandated.
• Subjects with medical conditions precluding surgery.
• Subjects whose lesions cannot be completely resected based on size or location, or where significant functional morbidity would be anticipated with further surgery.
• Patients refuse surgery.
• The justification for inclusion of patients with microinvasive disease is based reports demonstrating the ability of photodynamic therapy to successfully treat both dysplasia and T1 squamous cell carcinoma of the anal canal
• HPV positive by Cobas or other cytological assays within past 4 months
• Documented HIV positivity
• Patients must be on highly active anti-retroviral therapy with a CD4 count >200 for the past 12 months
• Viral load <200 for 12 months for the past 12 months
• ECOG performance status of 0-1.
• 18 years of age or older.
• Study subjects capable of providing informed consent.
• Women of childbearing potential and men must agree to use a medically accepted method of birth control from the time they sign consent and until one month after receiving ALA

Exclusion criteria

• Study subjects in whom the lesion has invasive squamous cell carcinoma of the anal cavity which is clinically appreciable.
• Clinically occult microinvasive squamous cell carcinoma of the anal cavity which is not focal.
• Study subjects who are pregnant or lactating .
• Study subjects who have a platelet count of less than 100,000/cubic mm.
• Study subjects with elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, or total bilirubin levels >2X normal or a history of chronic liver disease or cirrhosis of the liver.
• Significant cardiovascular history that would put the study subject at risk from hypotension that may occur with ALA
• Study subjects with porphyria or hypersensitivity to porphyrins.
• Administration of the following compounds: tetracyclines, sulfonamides, fluoroquinolones within 48 hours, or hypericin extracts within a week prior to light administration.
• Study subjects with abnormal baseline creatinine level or diagnosed kidney disease.
• Treatment with 5-FU, Imiquimod, trichloroacetic acid or ablative therapy within the previous month.
• Study subjects who have a medical history of immune suppression. This will include patients with a past transplantation requiring ongoing immunosuppressive medications.
• A history of sarcoidosis, hyperphosphatemia, or known kidney stones