Patient case: 74-year-old female with melanoma; genetic feature: no tumor infiltrating lymphocytes

Clinical trial: Vaccine Therapy Using Melanoma Peptides for Cytotoxic T Cells and Helper T Cells in Treating Patients With Metastatic Melanoma

Summary: RATIONALE: Vaccines made from peptides may make the body build an immune response to kill tumor cells.
  PURPOSE: This randomized phase II trial is studying four different vaccines using melanoma peptides from cytotoxic T cells and helper T cells to see how well they work in treating patients with metastatic melanoma.

Detailed description: OBJECTIVES:
  -  Compare the cytotoxic T-cell response to each of 12 melanoma peptides restricted by Human Leukocyte Antigen (HLA)-A1, -A2, or -A3 in patients with metastatic melanoma vaccinated with or without these 12 melanoma peptides and with or without helper peptides.
  -  Compare the helper T-cell response to each of 6 melanoma helper peptides restricted by HLA-DR molecules in patients treated with these vaccinations.
  -  Determine whether the addition of 6 melanoma helper peptides to a vaccine containing multiple class I Major histocompatibility complex (MHC)-restricted peptides augments T-cell responses to the class I restricted peptides in these patients.
  -  Determine, preliminarily, whether booster vaccination maintains immune response in patients treated with these vaccinations.
  -  Compare the rates of clinical response and survival in patients treated with these vaccinations.
  -  Determine, preliminarily, whether cellular immune response correlates with clinical response and survival rates in patients treated with these vaccinations.
  OUTLINE: This is a randomized, multicenter study. Patients are stratified according to HLA type (HLA-A1 vs HLA-A2 vs HLA-A1 and -A2 vs HLA-A3) and planned sentinel immunized node biopsy (yes vs no). Patients are randomized to 1 of 4 treatment arms.
  -  Arm I: Patients receive 2 injections of multi-epitope peptide vaccine comprising 12 melanoma peptides restricted by Class I MHC (12MP) emulsified with sargramostim (Granulocyte-macrophage colony-stimulating factor, GM-CSF) and Montanide ISA-51 or Montanide ISA-51 VG (ISA-51) intradermally (ID) and subcutaneously (SC) on day 1 of weeks 1-3 and 1 injection at the primary site only on day 1 of weeks 5-7.
  -  Arm II: Patients receive 2 injections of multi-epitope peptide vaccine comprising 12MP and 1 tetanus helper peptide emulsified with GM-CSF and ISA-51 ID and SC on day 1 of weeks 1-3 and 1 injection at the primary site only on day 1 of weeks 5-7.
  -  Arm III (closed to accrual as of 5/19/08): Patients receive 2 injections of multi-epitope peptide vaccine comprising 12MP and 6 melanoma helper peptides (6HP) emulsified with GM-CSF and ISA-51 ID and SC on day 1 of weeks 1-3 and 1 injection at the primary site only on day 1 of weeks 5-7.
  -  Arm IV: Patients receive 2 injections of multi-epitope peptide vaccine comprising 6HP emulsified with GM-CSF and ISA-51 ID and SC on day 1 of weeks 1-3 and 1 injection at the primary site only on day 1 of weeks 5-7.
  In all arms, patients continue therapy in the absence of unacceptable toxicity or disease progression necessitating other urgent therapy.
  Patients are evaluated at 8 and 12 weeks. Beginning 2-3 weeks after the week-12 evaluation, patients with no evidence of disease progression may receive booster vaccinations according to their randomized treatment arm. Patients receive booster vaccination ID and SC once weekly for 3 weeks. Treatment repeats every 9 weeks for 1 course, every 12 weeks for 2 courses, and then every 24 weeks for 2 courses OR for up to 2 years (whichever comes first) provided the patient does not require an urgent change in therapy.
  After completion of study treatment, patients are followed every 6 months for 2 years and then for survival for 5 years from study randomization.
  ACTUAL ACCRUAL: A total of 175 patients were accrued for this study during March 2005 and January 2009.

Eligibility: Inclusion Criteria:
  -  Histologically confirmed stage IV melanoma
  -  Multiple primary melanomas allowed
  -  Metastasis may be from a cutaneous, mucosal, ocular, or unknown primary site
  -  Measurable disease by Response Evaluation Criteria In Solid Tumors (RECIST criteria)
  -  Must have 2 extremities uninvolved with tumor
  -  Must have at least 2 intact (undissected) axillary and/or inguinal lymph node basins
  -  Prior sentinel node biopsy may not have violated the integrity of a nodal basin
  -  This extremity may still be considered for vaccination
  -  Human Lymphocyte Antigen (HLA)-A1, -A2, or -A3 positive
  -  Prior brain metastases allowed provided all of the following are true:
  -  Surgically resected or treated with gamma-knife or stereotactic radiosurgery
  -  No disease progression in the brain for the past 3 months
  -  More than 30 days since prior steroids for the management of brain metastases
  -  Age: 18 and over
  -  Eastern Cooperative Oncology Group (ECOG) performance status of 0-1
  -  Adequate organ function measured within 4 weeks before randomization:
  -  White blood cell (WBC) at least 4,000/mm^3
  -  Platelet count at least 100,000/mm^3
  -  Lymphocyte count at least 700/mm^3
  -  Serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT) no greater than 2 times upper limit of normal (ULN)
  -  Bilirubin no greater than 2 times ULN
  -  Alkaline phosphatase no greater than 2 times ULN
  -  Lactic dehydrogenase no greater than 2 times ULN
  -  Creatinine no greater than 1.8 mg/dL
  -  Negative pregnancy test
  -  Fertile patients must use effective contraception
  -  No other malignancy within the past 5 years except nonmetastatic squamous cell or basal cell skin cancer, ductal or lobular carcinoma in situ of the breast, or carcinoma in situ of the cervix
  -  At least 4 weeks since prior sargramostim (GM-CSF), interferon alfa-2b, or interleukin-2
  -  More than 4 weeks since prior chemotherapy (6 weeks for nitrosoureas or mitomycin)
  -  More than 30 days since prior systemic corticosteroids, including any of the following:
  -  Therapeutic doses of oral steroids (e.g., prednisone or dexamethasone)
  -  Steroid inhalers (e.g., Advair)
  -  Topical steroids and nasal steroids with low systemic absorption (e.g., fluticasone) or steroids with low systemic absorption (e.g., triamcinolone hexacetonide) injected into a joint space allowed
  -  At least 4 weeks since prior local control or palliative radiotherapy and recovered
  -  Recovered from prior major surgery
  Exclusion criteria:
  -  More than 3 brain metastases
  -  Metastatic lesions greater than 2 cm
  -  Concurrent radiotherapy
  -  Prior radiotherapy to measurable disease
  -  Concurrent surgery
  -  Concurrent corticosteroids
  -  Concurrent topical or systemic steroids
  -  Concurrent chemotherapy
  -  Prior vaccination with any of the study peptides
  -  Recent (within the past year) or concurrent addiction to alcohol or illicit drugs
  -  Pregnant or nursing
  -  Known or suspected major allergy to any components of the study vaccine
  -  Significant detectable infection
  -  Immunosuppression conditions
  -  Prior or active autoimmune disorder requiring cytotoxic or mmunosuppressive therapy, except for any of the following:
  -  Presence of laboratory evidence of autoimmune disease (e.g., positive antinuclear antibody (ANA) titer) without symptoms
  -  Clinical evidence of vitiligo or other forms of depigmenting illness
  -  Mild arthritis requiring nonsteroidal anti-inflammatory medication
  -  Autoimmune disorder with visceral involvement

Relevance to patient case: not relevant