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

Clinical trial: APX005M in Combination With Systemic Pembrolizumab in Patients With Metastatic Melanoma

Summary: The goal of Part 1 of this clinical research study is to find the highest tolerable dose of APX005M that can be given with pembrolizumab that can be given to patients with metastatic melanoma.
  The goal of Part 2 of this study is to learn if the combination can help to control metastatic melanoma.
  The safety of this drug combination will also be studied.

Detailed description: Study Groups:
  If you are found to be eligible to take part in this study, you will be assigned to a study group based on when you join this study. Up to 4 groups of 3 participants will be enrolled in Part 1, and up to 20 participants will be enrolled in Part 2.
  If you are enrolled in Part 1, the dose of APX005M you receive will depend on when you join this study. The first group of participants will receive the lowest dose level of APX005M. Each new group will receive a higher dose of APX005M than the group before it, if no intolerable side effects were seen. This will continue until the highest tolerable dose of APX005M is found.
  If you are enrolled in Part 2, you will receive APX005M at the highest dose that was tolerated in Phase 1
  All participants will receive the same dose level of pembrolizumab.
  Study Drug Administration:
  APX005M will be injected directly into 1 tumor every 3 weeks (Weeks 0, 3, 6, and 9) for up to 4 doses.
  The injections may be done with or without the help of a ultrasound, CT, and MRI.
  If the doctor thinks it is needed, you may need to stay in the hospital overnight or be monitored by a caregiver for 24 hours after you receive APX005M.
  You will receive pembrolizumab by vein 1 time every 3 weeks (Weeks 0, 3, 6, 9, and 12). The first dose of pembrolizumab will be given 1-2 days before or after your first dose of APX005M.
  You will be given a diary to write down any injection site reactions you may have.
  Study Visits:
  Within 1 week before your first APX005M injection:
  -  You will have a physical exam.
  -  You will have a punch biopsy or image-guided biopsy of a tumor to check the status of the disease. To collect a biopsy, the area of skin is numbed with anesthetic and a small cut is made to remove all or part of the affected tissue. To collect a punch biopsy, the area of skin is numbed with anesthetic and a small cut is made to remove all or part of the affected tissue. To perform an image-guided biopsy, a needle is inserted into the affected area using imaging such as CT or ultrasound to collect cells or tissue from an organ, lymph node, or suspected tumor mass. The doctor will use the imaging to guide the needle into the area.
  -  Blood (about 1 teaspoon) will be drawn for routine tests.
  -  The tumors will be measured and photographed.
  On Day 1 of Cycle 1:
  -  You will have a physical exam.
  -  Blood (about 4 tablespoons) will be drawn for routine tests and test your immune system.
  -  The tumor will be measured and photographed.
  On Days 2 and 3 of Cycle 1:
  -  Your vital signs (blood pressure, heart rate, temperature, and breathing rate) will be measured.
  -  Blood (about 2 teaspoon) will be drawn for routine tests.
  -  You will have a biopsy of one of the injected tumor sites within 48 hours after the 1st injection to check the status of the disease.
  On Days 8 and 15 of Cycles 1 and 2:
  -  Your vital signs will be measured.
  -  Blood (about 2 teaspoons) will be drawn for routine tests.
  On Day 1 of Cycles 2-4:
  -  You will have a physical exam.
  -  Blood (about 4 tablespoons) will be drawn for routine tests and to test your immune system.
  On Day 1 of Cycle 3 (± 3 days):
  -  You will have a biopsy of one of the injected tumors and one of the tumors that you did not have an injection in to check the status of the disease.
  -  The tumors will be measured and photographed.
  -  You will have CT, MRI/CT, and/or an ultrasound to check the status of the disease.
  -  Blood (about 2 teaspoons) will be drawn for routine tests.
  On Day 1 of Cycles 5 and beyond:
  -  You will have a physical exam.
  -  Blood (about 2 teaspoon) will be drawn for routine tests.
  -  You will have CT, MRI/CT, and/or an ultrasound to check the status of the disease.
  On Day 1 of Cycle 5 (± 3 days) and then every 3-4 cycles:
  -  Blood (about 4 tablespoons) will be drawn for routine tests and to test your immune system.
  -  The tumors will be measured and photographed.
  -  You will have CT, MRI/CT, and/or an ultrasound to check the status of the disease.
  -  Blood (about 2 teaspoons) will be drawn for routine tests.
  Length of Treatment:
  You will be on study for up to 2 years. You will be taken off study if the disease gets worse, if intolerable side effects occur, or if you are unable to follow study directions.
  If your doctor thinks it is in your benefit, you may continue to receive pembrolizumab as standard of care after you are off this study. Your doctor will describe this in more detail.
  Off-Study Visit:
  If you have to go off study early because the disease got worse or you had intolerable side effects:
  -  You will have a physical exam.
  -  The tumors will be photographed and measured.
  -  Blood (about 4 teaspoons) will be drawn for routine tests and to test your immune system.
  -  You will have CT scans to check the status of the disease.
  Follow-Up:
  Within 2 weeks after your last study drug dose and every 8-12 weeks after that, you will have scans to check the status of the disease. Your doctor will decide what type of scans you will have.
  If you choose to seek care at another hospital, the study staff will call you every 3 months for up to 2 years after your last study drug dose. You will be asked how you are doing. The calls should last about 5 minutes.
  This is an investigational study. APX005M is not FDA approved or commercially available. It is currently being used for research purposes only. Pembrolizumab is FDA approved and commercially available for the treatment of metastatic melanoma. The combination of these drugs to treat metastatic melanoma is investigational.
  The study doctor can explain how the study drug is designed to work.
  Up to 41 participants will be treated in this study. All will take part at MD Anderson.

Eligibility: Inclusion Criteria:
  1. Histologically or cytologically confirmed malignant melanoma from skin, or mucosal melanoma (i.e. ocular melanoma subjects are not eligible)
  2. Measurable, unresectable stage III (in transit lesions) or stage IVA, IVB, IVC disease
  3. At least two injectable lesions (amenable for direct injection or through the use of image guidance such ultrasound [US], CT or MRI) defined as any injectable cutaneous, subcutaneous, nodal, or visceral melanoma lesion >/= 10 mm in longest diameter
  4. Age >/= 18 years
  5. ECOG performance status 0 or 1
  6. Total bilirubin less than or equal to 2.0 mg/dl, except in patients with Gilbert's Syndrome who must have a total bilirubin less than 3.0 mg/dl.
  7. Platelet count greater than or equal to 100,000/mm^3
  8. WBC >3000/mm^3
  9. ANC>= 1500/mm^3
  10. Hemoglobin >9 g/dL
  11. Serum ALT and AST <3 the upper limit of normal (ULN); <5 ULN if there is liver involvement secondary to the tumor
  12. Serum creatinine </= 2.0 mg/dl
  13. Seronegative for HIV antibody
  14. Patients with a negative pregnancy test (urine or serum) must be documented within 14 days of screening for women of childbearing potential (WOCBP). A WOCBP has not undergone a hysterectomy or who has not been naturally postmenopausal for at least 12 consecutive months (i.e. who has not had menses at any time in the preceding 12 consecutive months).
  15. Unless surgically sterile by bilateral tubal ligation or vasectomy of partner(s), the patient agrees to continue to use a barrier method of contraception throughout the study and for 4 months after the last dose of APX005M or Pembrolizumab such as: condom, diaphragm, hormonal, IUD, or sponge plus spermicide. Abstinence is an acceptable form of birth control.
  Exclusion Criteria:
  1. Patients who have previously received pembrolizumab or PD-/L1 blockade therapy. Adjuvant IFN-a, is allowed if last dose was received at least 6 months of starting study treatment.
  2. Active autoimmune disease requiring disease-modifying therapy.
  3. Concurrent systemic steroid therapy higher than physiologic dose (>7.5 mg/day of prednisone or equivalent).
  4. Any form of active primary or secondary immunodeficiency.
  5. Patients with history of hematologic malignancy.
  6. Active coagulopathy.
  7. History of New York Heart Association class 3-4 congestive heart failure or history myocardial infarction within 6 months of starting study treatment.
  8. History of arterial thrombosis within 3 months of starting study treatment.
  9. History of clinically manifested CNS metastases, except if brain metastases have been treated, are stable and are asymptomatic
  10. Prior malignancy except the following: adequately treated basal cell or squamous cell skin cancer, in-situ cervical cancer, thyroid cancer (except anaplastic) or any cancer from which the patient has been disease-free for 2 years.
  11. Subjects who have received prior immune checkpoint inhibitors (e.g., anti-PD-1, anti-PD-L1), anti-CD40 , or an oncolytic therapy or prior therapy with and TLR agonist.
  12. Subjects that have received experimental vaccines or other immune therapies should be discussed with the Principal Investigator to confirm eligibility.
  13. Active known clinically serious infections (> Grade 2 NCI-CTCAE version 4.03).
  14. Prior systemic therapy, radiation therapy, or surgery within the 28 days of starting study treatment.
  15. Prior systemic therapy, radiation therapy, or surgery within the 28 days of starting study treatment. Palliative radiotherapy to a limited filed or palliative cryoablation is allowed after consultation with the Principal Investigator, at any time during the study participation including screening.
  16. WOCBP who are pregnant or nursing

Relevance to patient case: not relevant