Patient case: 73-year-old male with melanoma; genetic feature: tumor cells negative for PD-L1 expression

Clinical trial: Multi-center Phase I/IIa Trial of an Autologous Tumor Lysate (TL) + Yeast Cell Wall Particles (YCWP) + Dendritic Cells (DC) Vaccine in Addition to Standard of Care Checkpoint Inhibitor of Choice in Metastatic Melanoma Patients With Stable or Slowly Progressing Disease.

Summary: Assess the safety and tumor response of utilizing an autologous tumor lysate, particle-loaded, dendritic cell (TLPLDC) vaccine given in combination with standard of care (SoC) checkpoint inhibitors (CPI) in patients with stage IV melanoma with stable or slowly progressing disease.

Detailed description: Metastatic melanoma patients on CPI monotherapy for a minimum of 3 months with stable or slowly progressing disease will be identified and screened for inclusion/exclusion criteria. Eligible patients will be counseled and consented for tissue procurement. They will undergo excisional or core needle biopsy as clinically indicated, and this tissue will be shipped in liquid nitrogen shippers through FedEx to our central facility in Greenville, SC. The tumor will be stored frozen until vaccine preparation. Vaccine development requires 48 hours for preparation. Upon verification that adequate tissue was obtained, these patients will then be counseled and consented for participation in the trial.
  The patients who qualify for participation in this trial will be categorized based on their tumor's response to CPI monotherapy. These patients will continue their treatment of CPI. Once consented, patients will receive a single injection of Neupogen (G-CSF) 300 μg SQ 24-48 hrs prior to having 70 mL of blood collected and sent to our central facility for DC isolation and preparation. Those who cannot tolerate Neupogen or refuse it will have 120 mL of blood drawn and sent. Additional blood may be drawn if additional vaccine doses need to be made or re-made for any reason. Vaccines will be prepared by producing TL through freeze/thaw cycling and then loaded into pre-prepared YCWP. The TL-loaded YCWP will be introduced to the DC for phagocytosis thus creating the TLPLDC vaccine, which will be frozen in single dose vials. Each vial will contain 1 x 106 TLPLDC and will be labeled with the patient's unique study number.
  The frozen autologous TLPLDC will be sent back to the site with a total of 6 single dose vials after the vaccine has completed QA/QC testing and lot-release (usually 3 weeks). The primary vaccination series will include monthly inoculations at 0, 1, 2, 3 months followed by boosters at 6 and 9 months in the same lymph node draining area (preferably the anterior thigh). Once received, the first inoculation should occur within 4 weeks.
  Safety data will be collected on local and systemic toxicities and graded and reported per the Common Terminology Criteria for Adverse Events (CTCAE) v4.03.
  Patients will follow-up at their respective sites for evaluation of metastatic disease per SoC. They will under imaging, CT/PET-CT, to meet Response Evaluation Criteria in Solid Tumors (RECIST) criteria version 1.1 and Guidelines for the Evaluation of Immune Therapy Activity in Solid Tumors to monitor disease.
  Blood (50 mL) will be collected from all patients prior to each inoculation and at 12 months from enrollment for a total of 7 time points or a total of 350 mL of blood over 1 year. The collected blood will be sent to our central facility for immunologic testing of T-cell responses.

Eligibility: Inclusion Criteria:
  -  18 years or older
  -  Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 (Appendix A)
  -  Metastatic melanoma on standard of care CPI monotherapy (treating physician's choice) with stable or slowly progressive disease. Patients will be divided into the following groups based on their tumor response characteristics to CPI monotherapy:
  1. No clinical response (PD de novo) after a minimum of 3 months on CPI monotherapy
  2. Develop PD after initial clinical response to CPI monotherapy
  3. Stable disease for at least 6 months on CPI monotherapy
  -  Approximately 1 cm3 preferred but 1 mg minimum of accessible and dispensable tumor (minimum of 3 passes with a core needle)
  -  Able to continue their CPI treatment regimen
  -  Adequate organ function as determined by the following laboratory values:
  -  ANC ≥ 1,000/μL
  -  Platelets ≥ 75,000/μL
  -  Hgb ≥ 9 g/dL
  -  Creatinine ≤ 1.5 x upper limit of normal (ULN) or Creatinine clearance ≥ 50% of lower limit of normal (LLN)
  -  Total bilirubin ≤ 1.5 ULN
  -  ALT and AST ≤ 1.5 ULN
  -  For women of child-bearing potential, agreement to use adequate birth control (abstinence, hysterectomy, bilateral oophorectomy, bilateral tubal ligation, oral contraception, IUD, or use of condoms or diaphragms)
  Exclusion Criteria:
  -  Inability to continue treatment with CPI
  -  Rapidly progressing multi-focal metastatic melanoma
  -  Insufficient tumor available to produce vaccine
  -  ECOG >2 performance status (Appendix A)
  -  Immune deficiency disease or known history of HIV, HBV, HCV
  -  Receiving immunosuppressive therapy including chronic steroids (except physiologic maintenance doses), methotrexate, or other known immunosuppressive agents
  -  Pregnancy (assessed by urine HCG)
  -  Breast feeding
  -  Active pulmonary disease requiring medication to include multiple inhalers (>2 inhalers and one containing steroids)
  -  Involved in other experimental protocols (except with permission of the other study PI)

Relevance to patient case: not relevant