Personalized Peptide Vaccine in Treating Patients With Advanced Pancreatic Cancer or Colorectal Cancer

Study Overview
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Brief Summary
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This phase I trial studies the side effects and best way to give personalized peptide vaccine in patients with pancreatic or colorectal cancer that has spread to other places in the body and usually cannot be cured or controlled with treatment (advanced). Personalized peptide vaccine is a vaccine developed from patient's own tumor cells and blood in order to use as a biological therapy. Biological therapies, such as personalized peptide vaccine may attack tumor cells and stop them from growing or kill them.

Detailed Description
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PRIMARY OBJECTIVES: I. Demonstrate that developing a custom vaccine for metastatic pancreatic ductal adenocarcinoma (PDA) and colorectal cancer (CRC) patients is feasible. (cohorts A and B) II. Show that a custom peptide-based vaccine in combination with imiquiomod, pembrolizumab, and/or sotigalimab (APX005M) is safe. (cohorts A and B and C and D) SECONDARY OBJECTIVES: I. Determine the clinical benefit of the peptide vaccine alone or combined with pembrolizumab or pembrolizumab and APX005M. (cohorts A and B and C and D) II. Demonstrate the antigenicity of each vaccine. (cohorts A and B and C and D) III. The change in neoantigen-specific T cell responses at 12 weeks after initiation of personalized peptide vaccination. (cohorts C and D) IV. Relapse-free survival and circulating tumor deoxyribonucleic acid (ctDNA) clearance rate. (cohorts C and D) OUTLINE: Patients are assigned to 1 of 3 cohorts. COHORT A: Patients receive personalized synthetic tumor-associated peptide vaccine therapy subcutaneously (SC) on day 1 of weeks 0, 1, 3, 4, 6, 12, and 24. Beginning 15 minutes after each vaccine is administered, patients then receive imiquimod cream topically in the absence of disease progression or unacceptable toxicity. Patients also undergo computed tomography (CT) or magnetic resonance imaging (MRI) scans at baseline and at weeks 0 and 6, then every 3 months, and at week 39. COHORT B: Patients receive personalized synthetic tumor-associated peptide vaccine therapy SC on day 1 of weeks 0, 1, 3, 4, 6, 12, and 24. Beginning 15 minutes after each vaccine is administered, patients receive imiquimod cream topically. Patients also receive pembrolizumab intravenously (IV) over 30 minutes every 3 weeks until week 24 in the absence of disease progression or unacceptable toxicity. Patients also undergo CT or MRI scans at baseline and at weeks 0 and 6, then every 3 months, and at week 39. COHORTS C AND D: Patients receive personalized synthetic tumor-associated peptide vaccine therapy SC on day 1 of weeks 0, 1, 3, 4, 6, 9, 12, 15, 18, 21, and 24. Beginning 15 minutes after each vaccine is administered, patients receive imiquimod cream topically. Patients also receive pembrolizumab IV over 30 minutes every 3 weeks until week 24 in the absence of disease progression or unacceptable toxicity. Beginning about 1 hour after each vaccine, patients also receive sotigalimab IV over 60 minutes on day 1 of weeks 0, 1, 3, 4, 6, 9, 12, 15, 18, 21, and 24 in the absence of disease progression or unacceptable toxicity. Patients also undergo CT or MRI scans at baseline and weeks 6,12, and 24, then every 3 months, and at week 39. After completion of study treatment, patients are followed for 6 months.

Official Title
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Pilot Study of the Feasibility and Safety of a Personalized Peptide Vaccine in Patients With Advanced Pancreatic Ductal Adenocarcinoma or Colorectal Adenocarcinoma

Conditions
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Metastatic Colorectal Adenocarcinoma, Metastatic Pancreatic Ductal Adenocarcinoma, Stage IV Colorectal Cancer AJCC v7, Stage IV Pancreatic Cancer AJCC v6 and v7, Stage IVA Colorectal Cancer AJCC v7, Stage IVB Colorectal Cancer AJCC v7

Intervention / Treatment
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* Drug: Imiquimod
* Biological: Pembrolizumab
* Biological: Sotigalimab
* Biological: Synthetic Tumor-Associated Peptide Vaccine Therapy
* Procedure: Computed Tomography
* Procedure: Magnetic Resonance Imaging


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: COHORTS A AND B: Patients must have metastatic pancreatic ductal adenocarcinoma (PDA) or metastatic colorectal cancer (CRC) to be eligible (PDA patients with an elevated tumor marker following a primary pancreatic surgery would be eligible) Patients can have any lines (including zero) of prior therapy to sign consent prior to tissue harvest; vaccination will not take place until at least one line of standard chemotherapy is given Patients must have adequate fresh or frozen tissue available or planned to be obtained; for cohort C and D patients should have estimated adequate tumor tissue that is planned to be resected (approximately > 1 cm cross-sectional size on radiographic imaging); subjects may have tissue collected under protocol PA15-0176 Age >= 18 years Eastern Cooperative Oncology Group (ECOG) performance status =< 1 (Karnofsky >= 70%) Life expectancy of greater than 6 months (12 months for cohort C and 9 months for cohort D) Absolute neutrophil count (ANC) >= 1,000/mcL Platelets >= 75,000/mcL Total bilirubin =< 2.0 x institutional upper limit of normal Aspartate aminotransferase (AST)(serum glutamic oxaloacetic transaminase [SGOT])/alanine aminotransferase (ALT)(serum glutamate pyruvate transaminase [SGPT]) =< 2.5 x institutional upper limit of normal (=< 5 X if known liver metastases or due to ongoing chemotherapy treatment defined as chemotherapy within 3 weeks prior to lab draw) (except in Gilbert's disease where direct bilirubin will be used) Calculated creatinine clearance >= 40 mL/min/1.73 m^2 Patients must demonstrate an ability to understand and the willingness to sign a written informed consent document The effects of a peptide-based vaccine, pembrolizumab or APX005M on the developing human fetus are unknown; for this reason, women of child-bearing potential and men must agree to use adequate contraception at study entry and for the duration of study participation; should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately; birth control specifications: unless surgically sterile by bilateral tubal ligation or vasectomy of partner(s), sexually active participants must use birth control during and for > 120 days after the study; abstinence is also an acceptable form of birth control FOR COHORT C ONLY: Patients must have metastatic colorectal cancer (CRC) and are planned to or have undergone complete (R0 or R1) metastectomy/ies (liver or peritoneal or lung or other organ site); the presence of nonspecific lung lesions < 1 cm are allowed FOR COHORT C ONLY: Agreement to have post-operative blood test to determine plasma mutation ctDNA positivity drawn within 6 weeks following surgical resection FOR COHORT D ONLY: Patients must have localized or metastatic PDA and are planned for complete resection (R0 or R1) FOR COHORT D ONLY: Agreement to have post-operative blood test to determine plasma mutation ctDNA positivity drawn within 6 weeks following surgical resection JUST PRIOR TO FIRST VACCINATION (WITHIN 21 DAYS): ECOG performance status 0-1 (Karnofsky >= 60%) JUST PRIOR TO FIRST VACCINATION (WITHIN 21 DAYS): Life expectancy of greater than 6 months JUST PRIOR TO FIRST VACCINATION (WITHIN 21 DAYS): Patients must have either measurable disease per Response Criteria in Solid Tumors (RECIST) version (v)1.1 or evaluable disease defined as an elevated tumor biomarker (CA19-9, carcinoembryonic antigen [CEA] or ctDNA mutation); pancreatic cancer patients with an elevated tumor marker following a primary pancreatic surgery would be eligible (cohorts A and B only) FOR COHORT C AND D ONLY: Patients must have plasma mutation ctDNA positivity within 6 weeks following surgical resection or ctDNA positivity on any serial testing timepoint if the initial ctDNA timepoint was negative or testing failure occurred. * An elevated CA19-9 (above MDACC upper limit of normal, > 35 U/ml) will serve as a ctDNA positive equivalent (Cohort D only) FOR COHORT C AND D ONLY: Completion of all planned adjuvant anti-cancer therapy FOR COHORT C AND D ONLY: Radiographic disease status is not relevant to inclusion for treatment Exclusion Criteria: Known history of testing positive for human immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome (AIDS); HIV-positive patients on combination antiretroviral therapy are ineligible because of the potential for lack of efficacy of therapeutic cancer vaccine Patients with known brain metastases should be excluded from this clinical trial because of their poor prognosis and because they often develop progressive neurologic dysfunction that would confound the evaluation of neurologic and other adverse events Subjects with active, known or suspected autoimmune disease; subjects with vitiligo, type I diabetes mellitus, residual hypothyroidism due to autoimmune condition only requiring hormone replacement, psoriasis not requiring systemic treatment, or conditions not expected to recur in the absence of an external trigger are permitted to enroll Subjects with a condition requiring systemic treatment with either corticosteroids (> 10 mg daily prednisone equivalents) or other immunosuppressive medications; inhaled or topical steroids and adrenal replacement doses > 10 mg daily prednisone equivalents are permitted in the absence of active autoimmune disease Uncontrolled concurrent illness including, but not limited to ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements Women of child bearing potential who are pregnant or breastfeeding; women with a positive pregnancy test at enrollment or prior to administration of vaccine Has history of (non-infectious) pneumonitis that required steroids, evidence of interstitial lung disease or active, non-infectious pneumonitis Known history of active TB (Bacillus tuberculosis) Hypersensitivity to vaccine, pembrolizumab, imiquimod or APX005M or any of its excipients Has a known additional malignancy that is progressing or requires active treatment Active coagulopathy History of arterial thrombosis within 3 months of starting study treatment History of New York Heart Association class 3-4 heart failure or myocardial infarction within 6 months of starting therapy Has a known history of hepatitis B (defined as being known hepatitis B surface antigen [HBsAg] reactive) or known active hepatitis C virus (defined as being known hepatitis C virus [HCV] ribonucleic acid [RNA] [qualitative] positive) infection JUST PRIOR TO FIRST VACCINATION (WITHIN 21 DAYS): Patients who have had chemotherapy or radiotherapy within 2 weeks prior to first treatment or those who have not recovered to baseline from adverse events due to agents administered more than 2 weeks earlier (washout period) JUST PRIOR TO FIRST VACCINATION (WITHIN 21 DAYS): Women of child bearing potential who are pregnant or breastfeeding Women with a positive pregnancy test prior to administration of vaccine JUST PRIOR TO FIRST VACCINATION (WITHIN 21 DAYS): Uncontrolled concurrent illness including, but not limited to ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements JUST PRIOR TO FIRST VACCINATION (WITHIN 21 DAYS): Patients may not be receiving any other investigational agents within 2 weeks prior to first treatment JUST PRIOR TO FIRST VACCINATION (WITHIN 21 DAYS): Has received a live vaccine within 30 days of planned start of study therapy * Note: Seasonal influenza vaccines and COVID-19 vaccines for injection are generally inactivated flu vaccines and are allowed; however intranasal influenza vaccines (e.g., Flu-Mist) are live attenuated vaccines, and are not allowed

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Cohort A (personalized vaccine, imiquimod)<br>Patients receive personalized synthetic tumor-associated peptide vaccine therapy SC on day 1 of weeks 0, 1, 3, 4, 6, 12, and 24. Beginning 15 minutes after each vaccine is administered, patients then receive imiquimod cream topically in the absence of disease progression or unacceptable toxicity. Patients also undergo CT or MRI scans at baseline and at weeks 0 and 6, then every 3 months, and at week 39. | Drug: Imiquimod<br>* Applied topically<br>* Other names: Zyclara;Biological: Synthetic Tumor-Associated Peptide Vaccine Therapy<br>* Given SC<br>Procedure: Computed Tomography<br>* Undergo CT<br>* Other names: CT;Procedure: Magnetic Resonance Imaging<br>* Undergo MRI<br>* Other names: NMR Imaging;|
| Experimental: Cohort B (personalized vaccine, imiquimod, pembrolizumab)<br>Patients receive personalized synthetic tumor-associated peptide vaccine therapy SC on day 1 of weeks 0, 1, 3, 4, 6, 12, and 24. Beginning 15 minutes after each vaccine is administered, patients receive imiquimod cream topically. Patients also receive pembrolizumab IV over 30 minutes every 3 weeks until week 24 in the absence of disease progression or unacceptable toxicity. Patients also undergo CT or MRI scans at baseline and at weeks 0 and 6, then every 3 months, and at week 39. | Drug: Imiquimod<br>* Applied topically<br>* Other names: Zyclara;Biological: Pembrolizumab<br>* Given IV<br>* Other names: SCH 900475;Biological: Synthetic Tumor-Associated Peptide Vaccine Therapy<br>* Given SC<br>Procedure: Computed Tomography<br>* Undergo CT<br>* Other names: CT;Procedure: Magnetic Resonance Imaging<br>* Undergo MRI<br>* Other names: NMR Imaging;|
| Experimental: Cohort C and D (vaccine, imiquimod, pembrolizumab, APX005M)<br>Patients receive personalized synthetic tumor-associated peptide vaccine therapy SC on day 1 of weeks 0, 1, 3, 4, 6, 9, 12, 15, 18, 21, and 24. Beginning 15 minutes after each vaccine is administered, patients receive imiquimod cream topically. Patients also receive pembrolizumab IV over 30 minutes every 3 weeks until week 24 in the absence of disease progression or unacceptable toxicity. Beginning about 1 hour after each vaccine, patients also receive sotigalimab IV over 60 minutes on day 1 of weeks 0, 1, 3, 4, 6, 12, and 24 in the absence of disease progression or unacceptable toxicity. Patients also undergo CT or MRI scans at baseline and weeks 6,12, and 24, then every 3 months, and at week 39. | Drug: Imiquimod<br>* Applied topically<br>* Other names: Zyclara;Biological: Pembrolizumab<br>* Given IV<br>* Other names: SCH 900475;Biological: Sotigalimab<br>* Given IV<br>* Other names: EPI-0050;Biological: Synthetic Tumor-Associated Peptide Vaccine Therapy<br>* Given SC<br>Procedure: Computed Tomography<br>* Undergo CT<br>* Other names: CT;Procedure: Magnetic Resonance Imaging<br>* Undergo MRI<br>* Other names: NMR Imaging;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of enrolled patients for whom a personalized vaccine is developed and ready to administer (cohorts A and B) |  | Up to 12 weeks post-enrollment | 
| Proportion of enrolled patients who receive at least 1 dose of vaccine at any time post-enrollment (cohorts A and B) |  | Up to 44 weeks | 
| Incidence of adverse events (AEs) | Defined as the proportion of subjects who experience at least one toxicity event per National Cancer Institute Common Toxicity Criteria for Adverse Events version 4.0. A toxicity event is defined as at least one grade 3 or 4 non-hematologic or grade 4 hematologic toxicity. Proportion of patients with AEs will be estimated, along with the Bayesian 95% credible interval. | Up to 24 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of patients who have received at least one dose of vaccine that is alive and progression free defined based on response criteria according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 | Progression free includes complete response (CR), partial response (PR), and stable disease (SD). The target proportion is 45%, and a proportion of 20% or lower will be considered as not having the desired efficacy. | At 12 weeks post-vaccination (second re-staging scan) | 
| Progression-free survival (cohorts A and B and C) | Estimated by the Kaplan-Meier method, along with the 95% confidence intervals, and log-rank test will be used to assess the time to event variable differences under different patient subgroups. | The time between the date of first vaccination and evidence of progression on computed tomography scan or the date of death due to any cause, assessed up to 6 months after the last dose of vaccine | 
| Response rate (cohort A and B) | Response rate includes both CR and PR and will be evaluated using a Simon optimal two-stage design. | Up to 12 weeks | 
| Change in tumor biomarker (CA19-9, carcinoembryonic antigen [CEA] or circulating free deoxyribonucleic acid [cfDNA] mutation) |  | Up to 6 months | 
| Overall survival | Estimated by the Kaplan-Meier method, along with the 95% confidence intervals, and log-rank test will be used to assess the time to event variable differences under different patient subgroups. | The time from first vaccination to death, assessed up to 6 months after the last dose of vaccine | 
| Recurrence-free survival (cohort C and D) | Estimated by the Kaplan-Meier method. | Up to 6 months | 
| Rate of circulating deoxyribonucleic acid (ctDNA) clearance (cohort C and D) | A linear mixed model will also be fitted to correlate ctDNA clearance and neoantigen-specific CD8+ T cell over time. | Up to 6 months | 
| Change in neoantigen-specific T cell response (cohort C and D) | The difference in log2 transformed T cell response from baseline to 12 weeks will be calculated for each peptide and patient. This endpoint will focus upon the log2-fold change at 12 weeks for the max peptide (i.e., the peptide with the greatest change). Descriptive statistics, including mean, standard deviation, median and range, will be used to summarize the changes. A paired t-test will be used to evaluate the changes from baseline to 12 weeks post initiation of vaccination. | Baseline to 12 weeks after initiation of personalized peptide vaccination | 
| Correlation of T-cell activation against vaccinated peptides and ctDNA dynamics (cohort C and D) |  | Up to 6 months | 
| Tumor microenvironment immune infiltration and progression biopsies (cohort C and D) |  | Baseline, up to 6 months | 
| T cell IFN-gamma release in response to selected personalized peptide antigens |  | Up to 6 months | 
| Levels of intracellular cytokine staining of T cells | Assessed by flow cytometry in response to stimulation with personalized peptide antigens. | Up to 6 months |