Conditions: Mucosal Melanoma Recurrent Melanoma Recurrent Uveal Melanoma Stage IIIA Skin Melanoma Stage IIIA Uveal Melanoma Stage IIIB Skin Melanoma Stage IIIB Uveal Melanoma Stage IIIC Skin Melanoma Stage IIIC Uveal Melanoma Stage IV Skin Melanoma Stage IV Uveal Melanoma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 11
Healthy volunteers: no

Brief summary:
This pilot phase II trial studies how well epacadostat and vaccine therapy work in treating patients with stage III-IV melanoma. Epacadostat may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Vaccines made from peptides and antigens may help the body build an effective immune response to kill tumor cells. Giving epacadostat with vaccine therapy may be an effective treatment for advanced melanoma.

Detailed description:
PRIMARY OBJECTIVES:

I. To determine the extent to which a regimen of INCB024360 (epacadostat) that normalizes serum kynurenine (Kyn)/ tryptophan (Trp) ratios alters the tumor microenvironment of melanoma, including determining the number and character of tumor-infiltrating lymphocytes as determined by examination of serial biopsies with immunohistochemistry (IHC) and gene signatures.

II. To determine the extent to which continued INCB024360 treatment plus the addition of the multipeptide melanoma vaccine, MELITAC 12.1 (MELITAC 12.1 peptide vaccine), further alters the tumor microenvironment of melanoma, including determining the number and character of tumor-infiltrating lymphocytes as determined by serial biopsies evaluating IHC and gene signatures.

SECONDARY OBJECTIVES:

I. To determine whether a regimen of INCB024360 that normalizes serum Kyn/Trp ratios plus MELITAC 12.1 vaccine changes the level or character of the vaccine-induced clusters of differentiation (CD) 8+ and CD4+ T-cell immune responses as measured in peripheral blood, as compared to prior published experience.

II. To evaluate the extent to which INCB024360 plus MELITAC 12.1 vaccine alters the number and character of peripheral blood mononuclear cell (PBMC) populations, including T and natural killer (NK) cells, as evaluated by multiparameter flow cytometry.

III. To evaluate the extent to which INCB024360 plus MELITAC 12.1 vaccine alters the PBMC transcriptome.

IV. To assess the safety and tolerability of INCB024360 plus MELITAC 12.1 vaccine.

V. To obtain preliminary data on the tumor response rate of INCB024360 plus MELITAC 12.1 vaccine by objective response rate (ORR), time to tumor progression, and overall survival.

VI. To associate any observed changes with the expression of IDO1 protein by IHC in tumor or tumor-infiltrating cells.

OUTLINE:

Patients receive epacadostat orally (PO) twice daily (BID) on days 1-98 and receive MELITAC 12.1 peptide vaccine intradermally (ID)/subcutaneously (SC) on days 21, 28, 35, 56, 77, and 98. Treatment with epacadostat may repeat every 98 days for up to 3 additional courses in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up for 1 year.

Arms:
arm 1: Patients receive epacadostat PO BID on days 1-98 and receive MELITAC 12.1 peptide vaccine ID/SC on days 21, 28, 35, 56, 77, and 98 for up to 3 additional courses in the absence of disease progression or unacceptable toxicity.

Interventions: intervention 1: Epacadostat intervention 2: MELITAC 12.1 Peptide Vaccine
Intervention descriptions: intervention 1: Given PO intervention 2: Given ID/SC

Protocol document:
Prot_SAP_000.pdf: 
NCI Protocol #: CITN-04 
Version Date: 27 Jan 2016 
1 
 
 
 
NCI Protocol #: 
CITN-04  
 
Local Protocol #: 
CITN-04 
 
TITLE: A Phase II Pilot Trial of an Indoleamine2,3, dioxygenase-1 (IDO1) Inhibitor 
(INCB024360) Plus a Multipeptide Melanoma Vaccine (MELITAC 12.1) in Patients with 
Advanced Melanoma  
 
(Advanced Melanoma – ICD-10053571) 
 
Coordinating Center: 
 
 
Cancer Immunotherapy Trials Network, Fred Hutchinson 
Cancer Research Center 
 
*Principal Investigator: 
Craig Slingluff, Jr., M.D. 
 
University of Virginia 
 
434-924-1730 
 
434-243-6844 
 
Cls8h@virginia.edu  
 
Co-Investigators: 
Mark S. Ernstoff, M.D. 
Taussig Cancer Institute R-35 
Cleveland Clinic Foundation 
9500 Euclid Ave 
Cleveland, OH 44195 
216-444-0888 
216-444-9464 
ernstom@ccf.org 
 
 
Brent Hanks, M.D. 
 
Duke University 
 
919-684-1995 
 
919-684-1818 
 
brent.hanks@duke.edu  
 
 
Keith Delman, M.D. 
 
Emory University 
 
404-778-3303 
 
kdelman@emory.edu 
 
 
David Lawson, M.D. 
 
Emory University 
 
404-778-1900 
 
dlawson@emory.edu  
 
Participation in the protocol is limited to the institutions and investigators listed above. 


NCI Protocol #: CITN-04 
Version Date: 27 Jan 2016 
 
2 
 
Statistician: 
 
Study Coordinator: N/A 
Zoe Moodie, Ph.D. 
Fred Hutchinson Cancer Research Center 
1100 Fairview Ave. N., M2-200 
Seattle, WA 98109-1024 
206-667-7077 
zoe@fhcrc.org 
 
 
  
Responsible Research Nurse: N/A 
Responsible Data Manager: N/A 
 
 
 
NCI Supplied Agent(s): N/A  
 
Non-NCI Supplied Agent(s)/Supplier(s): 
Indoleamine 2,3, dioxygenase-1 (IDO1) inhibitor (INCB024360), NSC #766086, Incyte 
Corporation  
 
MELITAC 12.1 vaccine, (12 Melanoma Peptides from MDP and CTA (12MP), NSC #728925, 
and Peptide-Tet, NSC #728927), University of Virginia 
 
Montanide ISA-51 VG, NSC #737063/, SEPPIC 
 
IND Sponsor: Fred Hutchinson Cancer Research Center, Cancer Immunotherapy Trials 
Network (CITN) – IND # 15691 
   
 
Protocol Type / Version # / Version Date: 
Amendment 8/Version 1.0/ 27 Jan 2016   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


NCI Protocol #: CITN-04 
Version Date: 27 Jan 2016 
 
3 
 
CANCER TRIALS SUPPORT UNIT (CTSU) ADDRESS AND CONTACT INFORMATION 
 
To submit site registration 
documents: 
For patient enrollments:  
Submit study data    
CTSU Regulatory Office 
1818 Market Street, Suite 1100 
Philadelphia, PA 19103 
Phone – 1-866-651-CTSU 
Fax – 215-569-0206 
Please refer to the patient enrollment 
section for instructions on using the 
OPEN system. 
Data collection for this 
study will be done 
exclusively through 
Medidata Rave.  Please 
see the data submission 
section of the protocol for 
further instructions.  
 
Do not submit study data 
or forms to the CTSU 
Data Operations.  Do not 
copy the CTSU on data 
submission. 
 
   
The study protocol and all related forms and documents must be downloaded from the protocol-
specific Web page of the CTSU Member Web site located at https://www.ctsu.org.  Sites must use the 
current form version and adhere to the instructions and submission schedule outlined in the protocol. 
 
CITN sites should follow procedures outlined in the protocol for Site registration, Patient Enrollment, 
Adverse Event Reporting, Data Submission (including ancillary studies), and Drug Procurement. 
 
 
For questions unrelated to patient eligibility, treatment, or data submission contact the CTSU Help 
Desk by phone or e-mail:  
CTSU General Information Line – 1-888-823-5923, or ctsucontact@westat.com. All calls and 
correspondence will be triaged to the appropriate CTSU representative.  
For detailed information on the regulatory and monitoring procedures for CTSU sites please 
review the CTSU Regulatory and Monitoring Procedures policy located on the CTSU members’ website   
https://www.ctsu.org 
The CTSU Web site is located at   https://www.ctsu.org 
 
 


NCI Protocol #: CITN-04 
Version Date: 27 Jan 2016 
 
4 
 
SCHEMA 
 
 
Cohort 
INCB024360 
Dosing 
MELITAC 12.1 
Dosing 
Blood draws 
Tumor biopsies 
including FNA 
A 
 
Pts.enrolled 
>6 wks after 
failing anti-
PD-1/PDL-1 
 
300 mg po 
bid 
continuous 
for 98 days 
(3 months) 
Intradermal/subcutaneous 
Days 21, 28, 35, 56, 77, 
98 (Weeks 3, 4, 5, 8, 11, 
and 14) 
Pretreatment 
day 0 and on 
days 21, 42, 
98, and 112 
Days 0, 21, 42, and 
(optional day 112) and 
(optional when coming 
off study including for 
progression) 
B 
 
Pts.enrolled 
2-6 wks after 
failing anti-
PD-1/PDL-1 
100 mg po 
bid 
continuous 
for 98 days 
(3 months) 
Intradermal/subcutaneous 
Days 21, 28, 35, 56, 77, 
98 (Weeks 3, 4, 5, 8, 11, 
and 14) 
Pretreatment 
day 0 and on 
days 21, 42, 
98, and 112 
Days 0, 21, 42, and 
(optional day 112) and 
(optional when coming 
off study including for 
progression) 
All other pts. 
300 mg po 
bid 
Intradermal/subcutaneous 
Days 21, 28, 35, 56, 77, 
98 (Weeks 3, 4, 5, 8, 11, 
and 14) 
Pretreatment 
day 0 and on 
days 21, 42, 
98, and 112 
Days 0, 21, 42, and 
(optional day 112) and 
(optional when coming 
off study including for 
progression 
Abbreviations: bid, twice per day; FNA, fine-needle aspiration; po, orally; pre-tx, pretreatment; SC, subcutaneous  
All other patients enrolled who have not been treated with anti-PD1/PDL-1 will receive 300 mg BID INCB024360


NCI Protocol #: CITN-04 
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5 
 
TABLE OF CONTENTS 
SCHEMA 
……………………………………………………………………………..4 
1.  
OBJECTIVES ......................................................................................................................7 
1.1 
Primary Objectives ...............................................................................................................7 
1.2 
Secondary Objectives ...........................................................................................................7 
2. 
BACKGROUND .................................................................................................................8 
2.1 
Study Disease(s)...................................................................................................................8 
2.2 
CTEP and/or CIP IND Agent(s): N/A .................................................................................8 
2.3 
Other Agents ........................................................................................................................9 
2.4 
Rationale ............................................................................................................................15 
3. 
PATIENT SELECTION ....................................................................................................19 
3.1 
Eligibility Criteria ..............................................................................................................19 
3.2 
Exclusion Criteria ..............................................................................................................22 
3.3 
Inclusion of Women and Minorities ..................................................................................25 
4. 
REGISTRATION PROCEDURES ...................................................................................25 
4.1 
Registration Process ...........................................................................................................25 
5. 
TREATMENT PLAN ........................................................................................................27 
5.1 
Agent Administration .........................................................................................................27 
5.2 
Definition of Dose-Limiting Toxicity:...............................................................................31 
5.3 
General Concomitant Medication and Supportive Care Guidelines ..................................31 
5.4 
Duration of Therapy ...........................................................................................................33 
5.5 
Duration of Follow-up .......................................................................................................34 
5.6 
Criteria for Removal from Study .......................................................................................35 
6. 
DOSING DELAYS/DOSE MODIFICATIONS................................................................35 
6.1 
Delayed Visits for Reasons Other Than Toxicity ..............................................................38 
7. 
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS .............................39 
7.1 
Comprehensive Adverse Events and Potential Risks List(s) (CAEPRs) ...........................39 
7.2 
Adverse Event Characteristics ...........................................................................................46 
7.3 
Expedited Adverse Event Reporting ..................................................................................46 
7.4 
Routine Adverse Event Reporting .....................................................................................48 
7.5 
Secondary Malignancy .......................................................................................................48 
7.6 
Second Malignancy ............................................................................................................48 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................49 
8.1 
CTEP IND Agent(s): N/A ..................................................................................................49 
8.2 
INCB024360, Inhibitor of Indoleamine 2,3-dioxygenase (IDO, NSC # 766086) .............49 
8.3 
MELITAC 12.1 ..................................................................................................................51 
8.4 
Montanide ISA-51 VG .......................................................................................................54 
8.5 
Commerical Agent: N/A ....................................................................................................55 


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9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................55 
9.1 
Biomarker Studies ..............................................................................................................55 
9.2 
Laboratory Correlative Studies ..........................................................................................56 
9.3 
Special Studies: Cytokine and INCB024360 Blood Levels ..............................................61 
10. 
STUDY CALENDAR .......................................................................................................62 
11. 
MEASUREMENT OF EFFECT........................................................................................65 
11.1 
Antitumor Effect – Solid Tumors ......................................................................................66 
11.2 
Antitumor Effect – Hematologic Tumors - N/A ................................................................72 
11.3 
Other Response Parameters ...............................................................................................72 
12. 
DATA REPORTING/REGULATORY REQUIREMENTS .............................................72 
12.1   Data Reporting ...................................................................................................................73 
12.2 
CTEP Multicenter Guidelines ............................................................................................73 
12.3 
Collaborative Agreements Language – N/A ......................................................................73 
13. 
STATISTICAL CONSIDERATIONS...............................................................................74 
13.1 
Study Design/Endpoints.....................................................................................................74 
13.2 
Primary Endpoint ...............................................................................................................74 
13.3 
Sample Size/Accrual Rate ..................................................................................................74 
13.4 
Stratification Factors - None ..............................................................................................75 
13.5 
Analysis of Secondary Endpoints ......................................................................................75 
13.6 
Reporting and Exclusions ..................................................................................................75 
REFERENCES 
……………………………………………………………………………77 
APPENDIX A 
PERFORMANCE STATUS CRITERIA ..................................................81 
APPENDIX B 
CTEP MULTICENTER GUIDELINES ....................................................82 
APPENDIX C 
INFORMATION ON POSSIBLE DRUG INTERACTIONS ...................84 
APPENDIX D 
BIOASSAY TEMPLATES .......................................................................87 
APPENDIX E 
VACCINE PREPARATION .....................................................................88 
APPENDIX F 
PATIENT MEDICATION DIARY ...........................................................91 


NCI Protocol #: CITN-04 
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7 
 
1.  OBJECTIVES 
 
INCB024360 is an indoleamine 2,3-dioxygenase 1 (IDO1) inhibitor with the capacity to 
normalize serum kynurenine/tryptophan (Kyn/Trp) ratios. The goal of this trial is to determine 
alterations in the tumor microenvironment of melanoma, first using a regimen of INCB024360 
that normalizes serum Kyn/Trp ratios and then by adding a multiple peptide melanoma vaccine 
to INCB024360 treatment. The primary endpoint will be changes in the concentration and 
number of CD8+ cells, as CD8+ T cell number has been shown to have the best correlation with 
survival [Erdag 2012], with each patient serving as their own control. If substantial changes at 
sites of tumor are detected (i.e., changes in CD8+ T cell infiltration) in response to INCB024360 
alone or in combination with the vaccine, subsequent iterative trials will be developed to 
determine the individual contributions of each agent. 
 
1.1 
Primary Objectives 
 
Objective 1: To determine the extent to which a regimen of INCB024360 that normalizes 
serum Kyn/Trp ratios alters the tumor microenvironment of melanoma, including 
determining the number and character of tumor-infiltrating lymphocytes as determined by 
examination of serial biopsies with immunohistochemistry (IHC) and gene signatures  
 
Objective 2: To determine the extent to which continued INCB024360 treatment plus the 
addition of the multipeptide melanoma vaccine, MELITAC 12.1, further alters the tumor 
microenvironment of melanoma, including determining the number and character of 
tumor-infiltrating lymphocytes as determined by serial biopsies evaluating IHC and gene 
signatures 
 
1.2 
Secondary Objectives 
 
Objective 3: To determine whether a regimen of INCB024360 that normalizes serum 
Kyn/Trp ratios plus MELITAC 12.1 vaccine changes the level or character of the 
vaccine-induced CD8+ and CD4+ T-cell immune responses as measured in peripheral 
blood, as compared to prior published experience  
 
Objective 4: To evaluate the extent to which INCB024360 plus MELITAC 12.1 vaccine 
alters the number and character of peripheral blood mononuclear cell (PBMC) 
populations, including T and natural killer (NK) cells, as evaluated by multiparameter 
flow cytometry  
 
Objective 5: To evaluate the extent to which INCB024360 plus MELITAC 12.1 vaccine 
alters the PBMC transcriptome  
 
Objective 6: To assess the safety and tolerability of INCB024360 plus MELITAC 12.1 
vaccine  
 


NCI Protocol #: CITN-04 
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8 
 
Objective 7: To obtain preliminary data on the tumor response rate of INCB024360 plus 
MELITAC 12.1 vaccine by objective response rate (ORR), time to tumor progression, 
and overall survival  
 
Objective 8: To associate any observed changes with the expression of IDO1 protein by 
IHC in tumor or tumor-infiltrating cells  
 
 
2. BACKGROUND 
 
2.1 
Study Disease(s) 
 
Melanoma represents only 6% of all skin cancer diagnoses, however, it accounts for 
about 85% of all skin cancer–related deaths [NCI 2012]. The number of new invasive 
cutaneous melanoma cases projected during 2010 was 68,000—a 23% increase from the 
2004 prediction of 55,100 cases. In 2015, the lifetime risk of developing melanoma is 
estimated to increase to 1 in 50 [Cockerell 2012].  
 
Existing therapy for melanoma consists of adequate surgical resection of the primary 
tumor and, in some circumstances, surgical resection of isolated metastases. Most of the 
patients on the current trial will have disseminated disease and be enrolled after failure of 
standard therapies. “Little consensus exists regarding standard chemotherapy for patients 
with metastatic melanoma, which most likely reflects the low level of activity of older 
FDA approved agents” [NCCN 2012]. In general, disseminated disease can be managed 
by systemic therapy, clinical trial or supportive care. According to NCCN Guidelines, 
“preferred regimens include ipilumumab, vemurafenib for patients with documented 
BRAF mutation, treatment in a clinical trial and high-dose IL-2” [NCCN 2012]. 
“Although approval of ipilumumab and vermurafenib has significantly altered the initial 
management of patients with stage IV melanoma, each agent has unique limitations” 
[NCCN 2012] and might not be appropriate for all patients. Other regimens for 
disseminated disease “include dacarbazine, temozolomide, imatinib for tumors with c-
KIT mutations, dacarbazine- or temozolomide-based combination chemotherapy, or 
biochemotherapy (including cisplatin and vinblastine with or without IL-2, interferon 
alfa, paclitaxel as monotherapy or in combination with carboplatin [NCCN 2012]. These 
have demonstrated modest response rates under 20% in first-line and second-line 
settings.”  
 
Some of the patients on the current protocol might have in-transit metastases. According 
to the NCCN guidelines, “Treatment in the context of a clinical trial is the preferred 
option” [NCCN 2012].  
 
2.2 
CTEP and/or CIP IND Agent(s): N/A 
 


NCI Protocol #: CITN-04 
Version Date: 27 Jan 2016 
 
9 
 
2.3 
Other Agents 
 
Indoleamine 2,3-dioxygenase 
 
IDO is an enzyme that catabolizes the essential amino acid tryptophan to kynurenine 
[Munn 2007; Katz 2008; Löb 2009; Soliman 2010] and IDO activation plays an essential 
role in the immunological tolerance between mother and fetus. In pregnant women, IDO 
activation decreases the concentration of tryptophan in the blood and elevates levels of 
kynurenine, which, in healthy pregnancies, increases with placental development. As a 
consequence, inducing IDO expression in the trophoblast suppresses T-cell activity 
against the fetus [Tatsumi 2000]. In murine studies, the administration of the IDO 
inhibitor 1-methyl-tryptophan caused allogeneic fetal rejection [Munn 1998]. Thus, IDO 
induction in the trophoblast and placenta is sufficient to inhibit the immune system of the 
mother and prevent rejection of the fetus. 
 
In addition to its activation in pregnancy, IDO is also expressed by activated immune 
cells and inflammatory cells, including macrophages and dendritic cells. Expression of 
IDO dampens the immune responses [Brown 1991; Huang 2002; Mellor 2005; 
Schroecksnadel 2005]. Upregulation of IDO in inflammatory cells has been shown to 
provide potent immunosuppression in autoimmune disease, allergies, chronic 
inflammatory conditions, and chronic infection. Relevant to this protocol, IDO 
expression is also increased in macrophages and dendritic cells of melanoma metastases. 
Moreover, enhanced IDO expression in immune cells in the sentinel node is an 
independent prognostic factor [Speeckaert 2012]. 
 
IDO is also overexpressed by some cancer cells. Such overexpression leads to tryptophan 
depletion and kynurenine excess, leading to T-cell immunosuppression, which can 
prevent immune recognition and attack on malignant cells, and might afford a tumor-
derived mechanism of immune escape [Liu 2009]. Because of this, IDO expression and 
enzymatic activity correlates strongly with prognosis in multiple cancers. In particular, 
IDO1 has been observed to be chronically activated and overexpressed in many cancers, 
including ovarian, colorectal, pancreatic, and prostate cancers, and melanoma. IDO 
expression and enzymatic activity correlates strongly with prognosis in multiple cancers 
[Liu 2009]. The expression of IDO1 correlates with more extensive disease and is an 
independent prognostic factor for reduced overall survival.  
 
In one study, moderate to strong cytoplasmic IDO expression was present in all (15/15) 
melanoma lymph node metastases in patients with poor survival [Brody 2009]. In other 
tumor types, increased serum L-kynurenine concentrations predict a poor prognosis in 
patients with diffuse large B-cell lymphoma treated with R-CHOP (rituximab–
cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy [Yoshikawa 
2010]. In addition, increased tryptophan degradation and increased IDO activity led to 
increased Kyn/Trp ratio in patients with ovarian cancer when compared with healthy 
controls. Furthermore, higher stages of ovarian carcinoma were associated with a higher 
rate of tryptophan degradation, and Kyn/Trp ratios correlated strongly with 
concentrations of cytokine interleukin 6 (IL-6), soluble IL-2 receptor alpha, tumor 


NCI Protocol #: CITN-04 
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10 
 
necrosis factor alpha (TNF-alpha) receptor, and the macrophage marker, neopterin 
[Schroecksnadel 2005]. 
 
Increased serum Kyn/Trp ratios have also been shown to correlate with immunological 
effects and disease progression in lung cancer and other cancers [Liu 2009]. For example, 
patients with lung cancer had significantly higher Kyn levels, lower Trp serum levels, 
and elevated Kyn/Trp ratio compared to normal controls (Table 2.3) [Suzuki 2010]. 
Although substantial overlap between normal and lung cancer values was demonstrated, 
patients with more advanced cancer tended to have higher abnormal values. 
 
Table 2.3. Kyn and Trp Levels and Ratios in Patients with Lung Cancer vs Normal Controls 
Variable 
Normal controls 
Lung cancer 
P 
Kyn serum levels 
2.30±0.56 µM 
2.82±1.17 µM 
0.0036 
Trp serum levels 
71.1±11.8 µM 
62.6±15.8 µM 
0.0007 
Kyn/Trp ratio 
32.9±9 
47.1±21.3 
<0.0001 
Abbreviations: Kyn, kynurenine; Trp, tryptophan. 
 
2.3.1 INCB024360 
 
The novel small-molecule inhibitor of IDO1, INCB024360, is the first IDO1 selective 
inhibitor to undergo assessment in a human clinical trial. INCB024360 is specific for 
IDO1 with potency in the nanomolar range (IC50=7.1–12.7 nM) in both human tumor 
cells and dendritic cells, and reduces tryptophan-to-kynurenine conversion as assessed by 
biochemical and cellular assays [Koblish 2010; Liu 2010]. It is highly potent in reversing 
IDO1-mediated suppression of T-cell proliferation in a dose-dependent manner 
(EC50=17.7 nM) with potency consistent with its inhibition of tryptophan-to-kynurenine 
conversion. It demonstrates high selectivity and does not inhibit other tryptophan-
catabolizing proteins such as tryptophan 2,3-dioxygenase (TDO) or IDO2, nor does it 
influence tryptophan transporters. It has a greater than 1000-fold selectivity against a 
number of kinases, ion channels, receptors, and transporters, and does not significantly 
induce or inhibit cytochrome P450 enzymes. INCB024360 has an excellent preclinical 
pharmacokinetic profile with an oral bioavailability of 50% in rat and dog, with good 
tolerability and safety profiles in preclinical rodent and nonrodent studies of 28-day 
duration. 
 
2.3.1.1 
Animal Models 
In preclinical murine models, INCB024360 inhibited IDO1 systemically in tumors 
and in tumor-draining lymph nodes with associated reduced tumor growth and 
enhanced lymphocyte activity. In mice, plasma Kyn levels decreased within 1 hour of 
oral INCB024360 administration and remained at minimal levels for as long as 
plasma levels of INCB024360 exceeded 1.2 µM (corresponding to the cellular IC90 
value adjusted for plasma protein binding [~8 hours]). Consistent with specific 
inhibition of IDO1 by INCB024360, no reduction in plasma Kyn levels was observed 
in IDO1–genetically deficient mice, despite similar compound exposures.  
 
Furthermore, during maximal suppression of IDO1 by INCB024360 in wild-type 


NCI Protocol #: CITN-04 
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11 
 
mice, the plasma Kyn levels were similar to the baseline plasma levels in IDO1-
deficient mice, demonstrating that oral administration of INCB024360 results in 
efficient and selective IDO1 inhibition in vivo.  
 
Reduced levels of regulatory T cells (Tregs) were demonstrated in the syngeneic 
tumors in mice that were administered INCB024360, compared with tumors in 
control mice. As a single agent, INCB024360 inhibited the growth of CT26 colon 
tumors, which express high levels of endogenous IDO1 when grown in syngeneic 
BALB/c mice [Koblish 2010]. No effect was observed in tumor models using 
immunocompromised BALB/c nu/nu mice. Furthermore, the effect of chemotherapy 
appeared to be enhanced with INCB024360 in preclinical models: in CT26 tumor–
bearing mice, tumor growth was reduced by 33% when doxorubicin was administered 
alone, by 25% when INCB024360 was administered alone, and by 66% when 
administered in combination.  
 
2.3.1.2 
Clinical Study INCB024360-101 
INCB024360 is currently being evaluated in an ongoing Phase I study (INCB 24360-
101) conducted by Incyte Corporation in subjects with refractory solid tumors 
[ClinicalTrials.gov Identifier: NCT01195311]. The study has used a 3+3 dose 
escalation design, with doses of INCB024360 ranging from 50 mg once daily (qd) to 
700 mg twice daily (bid). A total of 52 subjects have been treated: 3 initiated 
treatment at 50 mg qd, 4 at 50 mg bid, 3 at 100 mg bid, 6 at 300 mg bid, 11 at 400 mg 
bid, 5 at 500 mg bid, and 4 at 700 mg bid. In the food effect expansion cohort, 
14 subjects were treated at 600 mg bid.  
 
INCB024360 has generally been well tolerated. The most common adverse events 
(AEs) (≥20%) include fatigue, nausea, decreased appetite, vomiting, constipation, 
abdominal pain, diarrhea, dyspnea, back pain, and cough. The most common grade 3 
or 4 AEs were abdominal pain, hypokalemia, and fatigue (9.6% each). Despite 1 
patient reporting a dose-limiting toxicity (DLT) of radiation pneumonitis at 300 mg 
bid, additional subjects were enrolled at this dose and no additional DLTs were 
reported. At 400 mg bid, 1 patient reported a DLT of grade 3 fatigue, with no 
additional DLTs at this dose level. Another patient at 400 mg bid developed 
asymptomatic and transient hypopituitarism after 1 cycle of therapy and was able to 
continue dosing with INCB024360. Among the 18 subjects treated at either 600 or 
700 mg bid, no DLTs were observed. Dose escalation was completed based on 
preliminary pharmacokinetic and pharmacodynamic data, which demonstrated that 
doses of INCB024360 above 300 mg bid achieved exposures exceeding the IC90 
determined in nonclinical models and, in pharmacodynamic assays, reached a plateau 
for Kyn/Trp levels and ratios. In the final cohort of 600 mg bid, the effect of food on 
INCB024360 absorption was evaluated. No objective responses were reported. At 
2 months, stable disease was seen in 15 patients and lasted ≥4 months in 7 patients. 
The main AE reported in subjects receiving more than 2 cycles of INCB024360 has 
been grade 1 or 2 fatigue.  
 


NCI Protocol #: CITN-04 
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12 
 
2.3.1.3 
Clinical Study (INCB024360-201) 
INCB 24360-201 is a Phase Ib/II study of INCB024360 in combination with 
ipilimumab in subjects with advanced melanoma. Between April and August 2012, 
8 subjects were enrolled in the Phase Ib portion of the study and were treated with 
INCB024360 300 mg bid (Cohort 1), 300 mg bid reduced to 100 mg bid (a 
continuation of Cohort 1 after hepatotoxity was identified), or 100 mg bid (Cohort 2), 
each in combination with 3 mg/kg of intravenous (IV) ipilimumab every 3 weeks. 
 
The initial 3 subjects treated with 300 mg bid of INCB024360 plus ipilimumab 
developed grade 3 or 4 elevations of aspartate aminotransferase/alanine 
aminotransferase (ALT/AST) on study days 76, 41, and 44, respectively. None of 
these subjects had elevated bilirubin, liver failure, or other evidence of severe liver 
injury. These subjects were discontinued from therapy and treated with IV 
methylprednisolone followed by oral prednisone on a tapering schedule until normal 
liver function recovered. At the time these elevations were reported, 4 additional 
subjects were already enrolled and receiving INCB024360 at 300 mg bid with 
3 mg/kg IV of ipilimumab. All 4 of these subjects were evaluated and were found to 
have normal liver function tests (LFTs). Yet, in response to the LFT elevations in the 
first 3 subjects on study and after discussions with the US Food and Drug 
Administration (FDA), the dose of INCB024360 was reduced to 100 mg bid in these 
4 subjects, and screening and enrollment continued to evaluate an initial dose of 
INCB024360 of 100 mg bid.  
 
After approximately 2–3 weeks of receiving the reduced dose of INCB024360, 2 of 
the 4 subjects who had a dose reduction developed hepatic toxicity, including 1 
subject symptomatic with abdominal discomfort and reported to have grade 4 
elevation of ALT and AST with grade 1 elevation of bilirubin and normal coagulation 
parameters. These 2 subjects improved after treatment with IV methylprednisolone 
and oral prednisone, until liver function parameters normalized. All 4 subjects 
received INCB024360 at 300 mg bid for 10, 13, 14, and 52 days, respectively, before 
having their dose reduced to 100 mg bid for 16–18 days. Among the 4 subjects who 
had their dose reduced, the 2 subjects who developed hepatic toxicity received 
INCB024360 at 300 mg bid for 13 and 14 days, respectively. The duration of 
exposure to INCB024360 at 300 mg bid was not clearly related to the risk of 
developing hepatic toxicity, since the subject with the longest exposure (52 days) did 
not develop hepatic toxicity after the dose reduction. Thus, a dose-response 
relationship might exist for the development of hepatic toxicity.  
 
After these additional reports of hepatic toxicity, all subjects were removed from 
study treatment, and screening for the study was suspended. An additional subject had 
been enrolled in Cohort 2 and received a single dose of INCB024360 at 100 mg at the 
time the decision was made to stop dosing INCB024360 in all subjects and to suspend 
enrollment into the study. This subject has continued to receive ipilimumab as part of 
standard treatment for advanced melanoma, with no hepatic toxicity reported. Among 
the 7 subjects in Cohort 1, 1 completed all 4 of the planned ipilimumab infusions 
while in the study. Three of the remaining 6 subjects have gone on to receive 


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additional doses of ipilimumab, including 1 who had developed hepatic toxicity from 
the combination of INCB024360 and ipilimumab. No additional hepatic toxicity has 
been reported in these subjects. The study was recently reopened and is evaluating 
lower doses of INCB024360 (25–100 mg bid) in combination with ipilimumab. Of 
note, in the Phase I study (INCB 24360-101), 7 subjects were enrolled with 
melanoma, including 4 with prior ipilimumab therapy. None of these subjects were 
reported to have related grade 3 or 4 elevations in LFTs.  
 
Plasma levels of INCB024360 and plasma levels of Kyn were measured in serial 
samples. Steady-state linear pharmacokinetics were obtained on or before day 8, and 
appreciable drug accumulation with increases in mean area under the curve (AUC) by 
30% between analysis on day 1 and 15 was evident. The half-life was 2.3–4 hours. 
Pharmacodynamic correlates suggest that significant target inhibition was achieved at 
bid doses ≥300 mg bid, resulting in steady-state exposures that exceeded the IC90. As 
a pharmacodynamic effect, blood samples for tryptophan and kynurenine levels show 
significant target inhibition with doses of 50 mg bid or greater. In patients showing 
elevations at baseline, ≥300 mg bid doses normalize kynurenine levels. IHC staining 
of 11 patients demonstrated that IDO1 tumor expression could be observed in tumor 
cells, infiltrating inflammatory cells, or both, in 10 out of 11 samples, and CD3+ T 
cells and Foxp3+ Tregs were present in all examined samples. Based on the 
tolerability and these pharmacokinetic and pharmacodynamic observations, a dose of 
600 mg bid has been determined as the recommended Phase-II dose as monotherapy.  
 
In recent preliminary results from a Phase ½ study of INCB024360 combined with 
ipilimumab in patients with advanced melanoma data showed that in immunotherapy-
naïve patients given 25 mg BID or 50 mg BID, 42% of patients demonstrated an 
objective response and 75% of patients demonstrated disease control by irRC. 
[Gibney; Hamid 2014] It is therefore proposed that reducing the dose of INCB024360 
from 600 mg BID to 300 mg BID in all patients may help prevent adverse events and 
dose limiting toxicities without limiting biological effect. 
 
In unpublished preliminary data from Incyte, kynurenine concentrations and the 
Kyn/Trp ratio were higher in the serum of most patients compared to controls and 
decreased to levels below the median for normal, after treatment with inhibitor when 
treated with doses that exceeded the IC90 (i.e., >300 mg bid [N=19 patients]) (Table 2.4).  
 
Table 2.4. Changes in Kynurenine Concentrations and Kyn/Trp Ratios 
Serum Variables 
Control 
Patients 
median 
Cancer Patients 
median (range) 
Post-inhibitor 
median (range) 
All patients (N=19) 
 
 
 
  Kynurenine, µM 
2.0 
2.1 (1.3–4.2) 
0.97 (0.5–1.7) 
  Kyn/Trp ratio, nmol/µmol 
29.9 
37.4 (17.8–68.9) 
18.3 (N/A) 
Select patients* 
 
 
 
  Kynurenine, µM 
2.0 
2.7 (2.1–4.2) 
1.1 (0.5–1.7) 
  Kyn/Trp ratio, nmol/µmol 
29.9 
42.0 (34–69) 
18.6 (8–43) 


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* with Kyn levels >2 µM (n=8) or Kyn/Tyr ratio >30 nmol/µmol (n=14) 
Abbreviations: Kyn, kynurenine; N/A, not available; Trp, tryptophan. 
 
2.3.2 MELITAC 12.1 Melanoma Vaccine 
 
MELITAC 12.1 consists of 12 melanoma-associated peptides from melanocytic 
differentiation proteins (tyrosinase and gp100) and cancer testis antigens (MAGE-A1, 
MAGE-A3, MAGE-A10, and NY-ESO-1), plus a tetanus peptide that binds 
promiscuously to HLA-DR molecules and stimulates Th1 dominant helper T cell 
responses (nonspecific tetanus helper peptide) [Slingluff 2001; Slingluff 2007]. In a 
Phase II clinical trial of adjuvant therapy in patients with resected stage IIB to IV 
melanoma, MELITAC 12.1 was found to be more efficacious (i.e., immune response was 
higher) and demonstrated more complete immunologic responses (i.e., greater cumulative 
T-cell responses) than vaccines with fewer peptides [Slingluff 2007]. The 12-peptide 
vaccine was found to induce substantially higher immune response rates: 100% of 
vaccinated patients had immune responses to at least 1 peptide (detectable in the blood in 
83% or in the sentinel immunized lymph nodes in 92%). The immunogenicity of 
individual peptides was maintained despite competition with additional peptides for 
binding to major histocompatibility complex (MHC) molecules, with a broader and more 
robust immune response. Clinical outcome with this peptide vaccine correlated with the 
immune responses measured in peripheral blood lymphocytes. In subsequent trials, 
Mel43 and Mel44, when administering the vaccine without granulocyte-macrophage 
colony-stimulating factor (GM-CSF), immunogenicity was significantly enhanced. In 
earlier trials with GM-CSF, immune responses were detected after in vitro sensitization. 
In subsequent trials without GM-CSF, immune responses could be detected directly ex 
vivo in 70–73% of patients [Slingluff 2011; Slingluff 2009]. 
 
This vaccine was well tolerated. In the most recent Mel44 trial (n=170), 8% of patients 
reported unexpected grade 3 treatment-related AEs, plus 10% with grade 3 injection-site 
ulceration and 7% with grade 3 injection-site induration; the injection-site reactions were 
expected and not dose-limiting. One grade 4 toxicity was reported (hypoglycemia, <1%). 
Other common toxicities were evident for approximately 24 hours and commonly 
included fatigue, dyspnea, headache, and myalgia. Mild AEs of rigors/chills, anorexia, 
nausea, sweating, fever, and flushing were commonly experienced [Slingluff 2011]. 
No concurrent comparator for efficacy was established in the nonrandomized trial of 
MELITAC 12.1. However, the disease-free survival (DFS) data with this multipeptide 
vaccine compared favorably to adjuvant trials of high-dose IFN (E1694 clinical trial), 
favorably with respect to studies E1684 and E1690, and analogously to the Canvaxin trial 
in patients with resected stage III melanoma. The median DFS was 35 months (2.9 years) 
with a corresponding 1-year DFS of 76% (95% confidence interval [CI], 60–86%), 2-year 
DFS of 59% (95% CI, 42–72%), and 3-year DFS of 47% (95% CI, 27–64%). In the more 
recent Mel43 and Mel44 trials, 3-year DFS was 52% in both trials (95% CI, 43–61%) and 
overall survival at 3 years was 76% (95% CI, 67–83%) and 79% (95% CI, 71–86%) 
respectively [Slingluff 2009; Slingluff 2011]. 
 


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This and similar multipeptide vaccine preparations have been evaluated in prospective 
randomized Phase II trials with several local adjuvants (e.g., GM-CSF, dendritic cells, 
incomplete Freund’s adjuvant [IFA]), systemic low-dose IL-2, and systemic 
cyclophosphamide [Slingluff 2004; Slingluff 2007; Slingluff 2009; Slingluff 2011]. 
Vaccination in IFA was more immunogenic than pulsing peptides on dendritic cells, a 
finding supported by a separate randomized trial [Slingluff 2003; O’Neill 2009]. No 
immunologic or clinical benefit was evident by adding low-dose IL-2, GM-CSF, or 
cyclophosphamide [Slingluff 2004; Slingluff 2009; Slingluff 2011]. Thus, the 
formulation proposed for this trial is peptide in IFA. 
 
2.4 
Rationale 
 
The central thesis of this protocol is that an inhibitor of IDO1 may decrease melanoma-
associated immune suppression and immune cell–associated immune suppression and 
increase the immune response at sites of tumor, specifically increasing both the total 
number of T cells and the number of melanoma antigen–specific T cells infiltrating the 
tumor. IDO expression and function arises from 2 potential sources: (1) tumors can 
overexpress IDO and (2) inflammatory cells can upregulate IDO in response to the IFN-
gamma secreted by activated T lymphocytes. Overexpressed and upregulated IDO 
subsequently depletes tryptophan and increases tryptophan catabolites, including 
kynurenine, that cause antigen-presenting cells (APCs) and cytotoxic T cells to be 
ineffective against established tumors. Data from animal experiments [Munn 2012] 
demonstrate that IDO induction after vaccination serves as a negative feedback loop that 
dampens the immune response to dendritic cell–based cancer vaccines. An effective IDO 
inhibitor may reverse this particular form of tumor-associated immune suppression and 
increase the response to tumor vaccines by augmenting T-cell responses to cancer 
antigens.  
 
A relatively nontoxic regimen of INCB024360 as monotherapy has been shown to 
normalize serum Kyn/Trp ratios in patients with cancer. That same regimen is 
hypothesized to inhibit the effect of IDO expression at sites of tumor deposition and 
thereby unleash the nascent or vaccine-induced antitumor immune response either at sites 
of tumor deposition or in the tumor-draining lymph nodes. In addition, the same regimen 
is hypothesized to increase the systemic immune response to cancer vaccines and/or 
allow vaccine-induced T cells to replicate and to function better at sites of tumor 
deposition. Because the melanoma multiple peptide vaccine, MELITAC 12.1, stimulates 
immune responses, has an excellent safety profile, and is presumed efficacious in the 
adjuvant setting, treating patients with INCB024360 before vaccination with MELITAC 
12.1 might increase the immune response to antigens expressed by melanoma cells and 
allow for an increased antitumor immune response.  
 
2.4.1 IDO Inhibition in Melanoma and T-cell Infiltration into Tumor  
 
IDO is strongly associated with poor prognosis [Gajewski 2005; Brody 2009], and 
dendritic cells in lymph nodes draining melanomas express IDO [Lee 2003]. High 
expression of IDO in the sentinel nodes of patients with melanoma is strongly associated 


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with increased tumor burden and shorter survival [Lee 2011; Speeckaert 2012]. On the 
other hand, a recent biomarker study found that high IDO expression in tumors before 
treatment was associated with improved outcome after therapy with ipilimumab, and that 
increases in T-cell infiltration during treatment were also associated with improved 
clinical outcome [Hamid 2011]. 
 
IDO is induced by IFN-gamma produced by T cells, and thus represents a potent immune 
regulatory pathway induced when activated T cells infiltrate tumors [Mackler 2003; 
Zhang 2011; Zhao 2012]. The findings from this recent study emphasize the highly 
complex interplay of immune activation and suppression in the melanoma 
microenvironment and its association with T-cell infiltration. They suggest that patients 
whose tumors express high levels of IDO are those with immune signatures for whom an 
immune therapy may have a higher chance of success, and that clinical benefit is 
associated with an increase in T-cell infiltration of melanoma metastases. 
2.4.2 Lymphocyte Infiltrates 
 
Patients with brisk lymphocytic infiltrates in primary melanomas have lower risk of 
metastasis and death than patients with sparse or absent infiltrate [Erdag 2012]. In 
addition, Slingluff has established that lymphocytic infiltrate in metastatic melanomas 
correlates with increased survival. Slingluff evaluated the composition and organization 
of immune cells that infiltrated 183 melanoma metastases in humans. CD45+ cell counts 
ranged from 0 to 2,142 per mm2 (Table 2.4.2). The most prevalent immune cells in the 
first metastases were T cells (53%), of which CD8+ T cells predominated (35%) and 
CD4+ T cells were less common (19%). B cells (CD20) and plasma cells (CD138) were 
present at high numbers (25% and 8%, respectively). Macrophage lineage cells (CD163) 
accounted for 13% of the infiltrates. NK cells (CD56) and mature dendritic cells (DC-
LAMP) were rare across all samples, with mean proportions of less than 1% each.  
 
Table 2.4.2. Distribution of Immune Cell Subsets Among 183 Metastases Studied [Erdag 
2012]  
Subset 
N 
Mean 
Min 
25% 
Median 
75% 
Max 
CD45 
183 
246 
0 
31 
117 
343 
2142 
CD138 
183 
26 
0 
0 
2 
23 
488 
CD20 
182 
65 
0 
0 
5 
47 
1796 
CD3 
183 
153 
0 
20 
83 
226 
1049 
CD4 
183 
52 
0 
3 
16 
60 
602 
CD8 
182 
103 
0 
15 
71 
153 
462 
CD56 
183 
3 
0 
0 
0 
2 
85 
PD1 
183 
18 
0 
0 
2 
20 
262 
Foxp3 
182 
19 
0 
0 
8 
23 
175 
CD163 
182 
39 
0 
2 
18 
53 
360 
DC-LAMP 
 
1 
0 
0 
0 
1 
19 
 
Three histologic patterns of immune cell infiltration were identified. Immunotype A was 
characterized by no immune cell infiltrate. Immunotype B was characterized by infiltration of 
immune cells limited only to regions proximal to intratumoral blood vessels. Immunotype C was 
characterized by a diffuse immune cell infiltrate throughout a metastatic tumor. These 


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immunotypes represented 29%, 63%, and 8% of metastases with estimated median survival 
periods of 15, 23, and 130 months, respectively. The best correlates with survival were with 
CD8+ T cells. Whereas higher densities of CD8+ T cells correlated best with survival, a higher 
density of CD45+ leukocytes, T cells, and B cells also correlated with increased survival. These 
reveal how the immune microenvironment can affect outcomes and also provide a method to 
quantify the effect of the IDO1 inhibitor on immune cell infiltration. 
 
2.4.3 Data on combination effects of checkpoint blockade antibodies and IDO inhibition.  
The success of checkpoint blockade therapy for melanoma has transformed the 
management of patients with advanced melanoma, but most patients treated with 
antibodies to CTLA4 or PD-1 will progress despite those therapies.  Combined therapy 
with antibodies to CTLA4 and PD-1 have induced higher response rates, and durable 
clinical benefit, but at the price of increased toxicity.  There is a need for additional 
combination therapies that may enhance clinical benefit, ideally at lower toxicity than 
combination of CTLA4 and PD-1 antibodies.  IDO and PD-1 can mediate immune escape 
of melanoma.  As effector T cells infiltrate melanoma metastases, they produce 
interferon-gamma, which in turn can induce both PD-L1 and IDO.  Blockade of PD-
1/PD-L1 can further increase T cell infiltration; so there is rationale to expect that IDO 
may mediate progression of cancer on PD-1 antibody therapy. [Spranger 2015], 
[Gajewski 2015 patent ] 
 
Combination of ipilimumab and the IDO inhibitor INCB024360 has induced significant 
transaminase elevations in 5 of 7 patients, when INCB024360 was administered at 300 
mg bid; the study was continued in 8 patients at a much lower dose of INCB024360 (25 
mg bid), with disease control observed in 6 of those 8 patients and irPR in 3 (38%). Thus, 
this small series suggests encouraging clinical outcomes with that combination, but there 
was unacceptable toxicity with a higher dose of INCB024360. Treatment of patients with 
another IDO inhibitor (D-1MT) after prior ipilimumab also was associated with dramatic 
toxicities, including hypophysitis, also raising questions about the toxicity of CTLA-4 
blockade plus IDO inhibition. 
 
PD-1 blockade with pembrolizumab or nivolumab has become standard first-line therapy 
for advanced melanoma (based on data reported in 2015); yet most patients treated with 
these agents will progress on therapy. Addition of IDO inhibition to these patients offers 
promise for improving clinical response rates, thus, a cohort has been added to allow 
addition of INCB024360 early after the last dose of PD-1 antibody (or PD-L1 antibody).  
If data from this cohort support safety and clinical activity of INCB024360 when added 
to patients progressing on PD-1 antibody, these data will support future study of adding 
INCB024360 while continuing PD-1 antibody after failure to respond.  Also, biopsies 
obtained after progression on PD-1 antibody and after adding INCB024360 will provide 
insight into the role of IDO in mediating failure of PD-1 inhibition and the changes in the 
tumor microenvironment of adding IDO blockade while PD-1 blockade remains active. 
 
 


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2.4.4 Correlative Studies 
 
To meet the primary objectives, tumors will be biopsied before therapy, after 3 weeks of 
INCB024360 treatment, and 1 week after the third vaccine plus INCB024360. Because 
immunotype and immunohistologic characteristics of tumor-infiltrating immune cells are 
associated with clinical outcome in metastatic melanoma [Erdag 2012], tumors will be 
assessed by IHC for T-cell infiltration patterns and infiltration with cells expressing CD8. 
CD8+ T cell infiltration will be reported as cells per mm2 of cross-sectional tumor area.  
 
Note: Optimally, patients will have tumor approachable for three serial biopsies during 
the trial.  For patients with only one or two tumors approachable for biopsy, available 
tumor blocks from prior biopsies (without intervening systemic treatment) can serve as 
the pretreatment sample. The biopsy after 3 weeks of INCB024360 will be considered 
essential.  Biopsy 1 week after the third vaccine plus INCB024360 will be considered 
optional. 
 
To characterize the immune cell infiltrate further, the tumors will also be assayed for a 
variety of antigens including CD4, CD8, CD56, CD34, CD45, CD20, CD3, CD8, CD138, 
CD163, DC-LAMP, FoxP3, and PD-1. IHC staining of tumor biopsies will also be 
performed to detect IDO1 expression, and the presence and patterns of CD8+ and CD4+ 
T cell infiltration, Foxp3 protein, and FoxP3 Treg infiltration. Gene signature will be 
assessed using an Affymetrix chip with focus on IFN signaling, IDO expression, and 
tumor rejection [Weiss 2011] with each patient serving as their own control. Gene 
signatures on the tumor will be determined by Ena Wang, PhD, and Franco Marincola 
MD, Chief, Infectious Disease and Immunogenetics Section in the Department of 
Transfusion Medicine, Clinical Center of the National Institutes of Health. 
 
A number of other (secondary) correlative studies will be conducted to evaluate whether 
a regimen of INCB024360 that normalizes serum Kyn/Trp ratios plus MELITAC 12.1 
vaccine changes the level or character of the vaccine-induced CD8+ and CD4+ T-cell 
immune responses as measured in peripheral blood, compared to each patient’s baseline. 
Evaluations will occur at baseline (week 0), again at week 3, week 6, some are done at 
week 14 and they are repeated optionally at week 16 only if the optional biopsy is done at 
week 16. Effector 8+ T-cell responses to MELITAC 12.1 will be measured by IFN-
gamma enzyme-linked immunosorbent spot assay (ELISpot) and with 
tetramers/multimers to 8 of the peptides in the vaccine. Effector CD4+ T-cell responses 
to MELITAC 12.1 will also be tested. Assays will be performed in the CITN Central 
Laboratory of the Tumor Vaccine Group led by Nora Disis, MD, in collaboration with the 
immune monitoring laboratory of Craig Slingluff, MD.  
 
The extent to which INCB024360 plus MELITAC 12.1 vaccine alters the number and 
character of PBMC (including T and NK cells as evaluated by multiparameter flow 
cytometry) will be calculated by assessing the effect on T lymphocyte number and 
phenotype (i.e., CD8+, effector memory CD8+, central memory CD8+, CD4+, CD4+ 
Treg, naïve subsets). The frequency and percentage of PBMC subsets will be determined 
using multiparameter flow cytometric analysis on whole blood. The markers include 


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CD3, CD8, CD4, CD56, Foxp3, CD127, CD45RA, CD45RO, CCR7, CD28, CD27, 
CD25, CD122, CD86, CD14, CD16, CD19, CD123, and CD11c. Changes in myeloid-
derived suppressor cell populations will also be assessed by flow cytometry. Assays will 
be performed in the CITN Central Laboratory of the Tumor Vaccine Group led by Nora 
Disis, MD, in collaboration with the immune monitoring laboratory of Craig Slingluff, 
MD.  
 
3. PATIENT SELECTION 
 
3.1 
Eligibility Criteria  
 
3.1.1 Patients must have malignant melanoma validated by histology or cytology. Patients may 
have had primary cutaneous, mucosal, or ocular melanoma or metastasis from an 
unknown primary site.  
 
NOTE: Patients must have measurable disease, defined as at least 1 lesion that can be 
accurately measured in at least 1 dimension (longest diameter to be recorded for non-
nodal lesions and short axis for nodal lesions) as ≥20 mm with conventional chest x-ray 
or as ≥10 mm with spiral computed tomography (CT) scan, magnetic resonance imaging 
(MRI), or calipers by clinical exam. See Section 11 for the evaluation of measurable 
disease.  
 
3.1.2 Unresectable stage III or IV melanoma validated by clinical criteria (including recurrent 
melanoma), or patients with multiple skin/soft tissue metastases of melanoma that may be 
resectable but are judged to have a future recurrence risk exceeding 70% (e.g., large 
adenopathy, distant skin metastases or multiple in-transit melanoma metastases). Tumor 
deemed amenable to biopsy (excisional, incisional, or core, with at least 100 mm3
 tumor 
volume per biopsy date) and fine-needle aspiration (FNA) biopsy.  
 
Note: Optimally, patients will have tumor approachable for three serial biopsies during 
the trial.  For patients with only one or two tumors approachable for biopsy, available 
tumor blocks from prior biopsies can serve as the pretreatment sample, but only if 
formalin-fixed tumor tissue is available and adequate to provide at least 20 unstained 
slides with sufficient tumor for analysis.  
 
NOTE:  Patients with unresectable advanced stage III or IV melanoma (including 
recurrent melanoma) are only eligible if they have failed at least one other first-line 
systemic therapy (other than adjuvant therapy). Exceptions to this requirement are those 
patients who have refused and/or are ineligible for other systemic therapies.  
 
NOTE: BRAFi should be considered for all ‘unresectable” or metastatic melanoma with 
BRAFV600E mutation; for low burden in-transit disease patients may enter trial without 
prior systemic therapy. 
 
3.1.2.1  Stage IV no evidence of disease (NED) is excluded by this criterion  
 


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3.1.3 Prior and concurrent therapy 
 
3.1.3.1 
Patients may have had prior systemic therapy without constraint on the number 
of prior treatment regimens except: 
a) Patients may not have had >450 mg/m2 doxorubicin  
b) Patients may not have had >3000 cGy to fields encompassing the entire 
pelvis 
 
3.1.3.2 
Patients must not be on any other systemic therapy within the following 
intervals before study enrollment:  
a) 1 week after stereotactic radiosurgery of the brain or comparable 
technology  
b) 4 weeks after cytotoxic chemotherapy or external beam radiation therapy  
c) 6 weeks after chemotherapy regimens including BCNU (carmustine) or 
mitomycin C 
d) patients who experience melanoma progression (by RECIST 1.1 criteria) 
while on or after treatment with PD-1 or PDL-1 antibody may enroll on this 
study.  
NOTE:  Patients must be off PD-1/PDL- antibody for at least 2 weeks to 
assess for delayed toxicity before being enrolled and receiving INCB024360. 
Patients who are enrolled 2 weeks and up to 6 weeks after the last dose of PD-
/PDL-1 antibody will enroll in cohort B and receive 100mg BID of 
INCB024360.  
Patients enrolled beyond the 6 week period after failing anti-PD-1/PDL-1 will 
be enrolled in cohort A. Cohort A patients will receive 300mg BID of 
INCB024360.  
Patients must not have active grade 2 autoimmune toxicities attributed to these 
antibodies at study entry. 
e) 8 weeks after ipilimumab, other CTLA-4 antibody or other 
immunologically active antibody.   
NOTE: Patients receiving prior CTLA-4, anti-PD1 antibody or other 
immunologic therapy must show evidence of normal pituitary function at 
baseline and must not have active grade 2 autoimmune toxicities attributed to 
these antibodies at study entry. 
 
 
3.1.4 Age ≥18 years  
 
[NOTE: Because insufficient dosing AE data are currently available on the use of 
INCB024360 in combination with MELITAC 12.1 in patients <18 years of age, children 
are excluded from this study, but will be eligible for future pediatric trials.] 
 
3.1.5 ECOG performance status 0–1 (Karnofsky ≥70%, see Appendix A). 
 


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3.1.6 Life expectancy of at least 6 months 
 
3.1.7 Patients must have normal organ and marrow function as defined below: 
 
 
leukocytes 
≥3,000/mcL 
 
absolute neutrophil count 
≥1,500/mcL 
 
platelets 
≥75,000/mcL 
 
hemoglobin 
>9g/dL 
 
total bilirubin 
<1.5 × institutional upper limit of normal 
 
[bilirubin <3 × institutional upper limit of normal  
 
for Gilbert’s syndrome] 
 
AST(SGOT)/ALT(SGPT) 
Up to 2.5 times ULN 
 
 
creatinine 
<1.5 × institutional upper limit of normal 
OR 
 
creatinine clearance 
≥60 mL/min/1.73 m2 for patients with creatinine 
 
levels above institutional normal. 
 
PT, INR 
≤1.5 × institutional ULN unless patient is 
therapeutically anticoagulated.  If on anticoagulants, PT/INR need to be within 
appropriate anticoagulation limits for the clinical indication.  Patients who are 
receiving anticoagulants may participate in the trial if their anticoagulation can be 
stopped safely for several days at the time of each biopsy.     
 
TSH,  
Up to 4 times ULN if T4 is normal  
 
T4 
Within normal limits.  If abnormal and patient is 
receiving thyroid replacement therapy, the thyroid medication may be adjusted and 
the T4 may be re-tested.   
 
3.1.8 Patients must express HLA-A1+, -A2+, or -A3+ (80% of patients) 
 
3.1.9 LDH <5 × upper limits of normal 
 
[NOTE: These criteria will select against patients with bulky disease and will select for 
patients with less disease and earlier disease.] 
 
3.1.10 Participants must not have had prior autoimmune disorders requiring cytotoxic or 
immunosuppressive therapy, or autoimmune disorders with visceral involvement. 
Participants must not have an active or inactive autoimmune disorders (e.g., rheumatoid 
arthritis, moderate or severe psoriasis, multiple sclerosis, inflammatory bowel disease, 
etc.) Participants who are receiving therapy for an autoimmune or inflammatory disease 
requiring these therapies are also excluded.  
3.1.11 The following will not be exclusionary:  
 
Resolved ipilimumab associated inflammatory disease 
 
The presence of laboratory evidence of autoimmune disease (e.g., positive antinuclear 
antibody [ANA] titer) without associated symptoms  
 
Subjects with vitiligo, thyroiditis, or atopic dermatitis, but otherwise not meeting this 
criterion may be enrolled. Individual cases can be discussed with the sponsor. 


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3.1.12 Not likely curable with surgery alone 
 
3.1.13 Not currently receiving therapy 
 
3.1.14 Females of childbearing potential must have a negative pregnancy test within 48 hours 
before initiating protocol therapy. 
 
NOTE: The effects of INCB024360 and MELITAC 12.1 on the developing human fetus 
are unknown. For this reason, women of child-bearing potential and men must agree to 
use adequate contraception (hormonal or barrier method of birth control or abstinence) 
before study entry and for the duration of study participation. Should a woman become 
pregnant or suspect she is pregnant while she or her partner is participating in this study, 
she should inform her treating physician immediately. Men treated or enrolled on this 
protocol must also agree to use adequate contraception before the study, for the duration 
of study participation, and 4 months after completing INCB024360 and MELITAC 12.1 
administration. 
NOTE: Subjects are considered not of child bearing potential if they are surgically 
sterile, have undergone a hysterectomy, bilateral tubal ligation, or bilateral 
oophorectomy, or are postmenopausal. Menopause is the age associated with complete 
cessation of menstrual cycles and menses, and implies the loss of reproductive potential. 
By a practical definition, the term assumes menopause after 1 year without menses with 
an appropriate clinical profile at the appropriate age. 
 
3.1.15 Ability to understand and willingness to sign a written informed consent document 
 
3.2 
Exclusion Criteria 
 
3.2.1 Patients who have had cytotoxic chemotherapy, radiotherapy, IFN, immunosuppressive 
therapy, or steroids within 4 weeks (6 weeks for nitrosoureas or mitomycin C) before 
entering the study or those who have not recovered from AEs due to agents administered 
more than 4 weeks earlier  
 
3.2.2 Ipilimumab, or other immunologically active therapy within 8 weeks of enrollment. 
NOTE: Patients who experience melanoma progression (by RECIST 1.1 criteria) while 
on or after treatment with PD-1 or PDL-1 antibody may enroll on this study (per section 
3.1.3.2 above) 
 
3.2.3 Active immunosuppressive therapy, including concurrent systemic immunosuppressive 
therapy or steroid therapy with more than 7 consecutive days of steroids within the prior 
4 weeks 
– The use of prednisone or equivalent <0.125 mg/kg/day (absolute maximum of 
10 mg/day) as replacement therapy is permitted.  
– Inhaled corticosteroids are permitted.  
 


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3.2.4 Cardiovascular disease that meets one of the following: congestive heart failure (New 
York Heart Association Class III or IV), active angina pectoris, or recent myocardial 
infarction or acute coronary syndrome (within the last 6 months) 
 
3.2.5 History of peripheral vascular disease (PVD) that has required surgical or percutaneous 
intervention or documented PVD that requires medical management with medications 
such as ASA + Clopidogrel.   Patients with Diabetes that is not well controlled are 
excluded from participation.  Not well controlled is defined as a Hgb A1C of greater than 
7.5%.   
 
3.2.6 Current or history of systemic autoimmune disease requiring systemic therapy, including 
significant autoimmunity associated with prior ipilimumab therapy or therapy with 
antibodies to PD-1 or PD-L1 
 
3.2.7 Cirrhosis, chronic hepatitis C virus positivity, or chronic hepatitis B infection. 
Subjects who may not tolerate immune-mediated hepatitis due to compromised hepatic 
reserve are also excluded from participation including:  1) Subjects with extensive liver 
metastasis (as judged by the investigator) 2) Subjects who drink more than two standard 
alcoholic beverages per day on a regular basis 3) Subjects who consume more than 2 
grams of Acetaminophen per day on a regular basis.   
– A positive hepatitis B serology indicative of previous immunization (i.e., HBsAb-
positive and HBcAb-negative), or a fully resolved acute hepatitis B infection is not an 
exclusion criterion. 
 
3.2.8 Patients who are receiving any other investigational agents for melanoma 
 
3.2.9 Patients who have had a grade one or grade two gastrointestinal adverse event during or 
after receiving anti-CTLA-4, anti-PD1 or anti-PD, without a colonoscopy verifying 
complete resolution of the adverse event. 
 
3.2.10 Patients who have experienced bowel perforation, neurologic involvement, Guillain 
Barré syndrome, Myasthenia Gravis, Steven Johnson syndrome and other intractable 
events or grade 4 non-laboratory toxicity. 
 
3.2.11 Uncontrolled intercurrent 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 
 
3.2.12 Pregnancy, nursing, or unwilling to take adequate birth control during therapy  
 
NOTE: Pregnant women are excluded from this study because INCB024360 and 
MELITAC 12.1 have the potential for teratogenic or abortifacient effects. Because of 
unknown but potential risks for AEs in nursing infants secondary to treatment of the 
mother with INCB024360 and MELITAC 12.1, breastfeeding should be discontinued if 
the mother is treated with INCB024360 and MELITAC 12.1 These potential risks may 


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24 
 
also apply to other agents used in this study. 
 
3.2.13 Known HIV or other history of immunodeficiency disorder  
 
NOTE: HIV-positive patients taking combination antiretroviral therapy are ineligible 
because of the potential for pharmacokinetic interactions with INCB024360 and 
MELITAC 12.1. In addition, these patients are at increased risk of lethal infections when 
treated with marrow-suppressive therapy. Appropriate studies will be undertaken in 
patients receiving combination antiretroviral therapy when indicated. 
 
3.2.14 Extensive active brain disease, including symptomatic brain metastases or the presence of 
leptomeningeal disease 
o Patients with brain metastasis, after definitive therapy with surgery or stereotactic 
radiation and stable off steroids for >4 weeks, are eligible. 
3.2.15  Any malignancy that has not been in complete remission for at least 3 years  
 
 
NOTE:  Patients with cured basal or squamous cell skin cancer are not excluded.  
 
 
   Patients with a history of excised in situ cancers, including breast, cervical,  
 
 
 
   colon, superficial bladder, prostate or other body system are not excluded. Study 
 
 
   entry will be allowed at the discretion of the Principal Investigator.  
 
 
NOTE:  Recurrence of the in situ cancer or tumor at the time of study entry would be  
 
 
   exclusionary. 
3.2.16 Monoamine oxidase (MAO) inhibitor use within the past 3 weeks or prior evidence of 
serotonin syndrome 
 
3.2.17 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to INCB024360, MELITAC 12.1, or other vaccine components 
 
3.2.18 Prior organ allograft or allogeneic transplantation, if the transplanted tissue is still in 
place 
 
3.2.19 Medical or psychiatric illness that would, in the opinion of the investigator, preclude 
participation in the study or the ability of patients to provide informed consent for 
themselves 
 
3.2.20 History of pulmonary disease such as emphysema or chronic obstructive pulmonary 
disease (COPD), (FEV1>60% of predicted for height and age). Pulmonary function tests 
(PFTs) are required in patients with prolonged smoking history or symptoms of 
respiratory dysfunction. 
 


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3.2.21 Use of any UGT1A9 inhibitor including: acitretin, amitriptyline, androsterone, 
cyclosporine, dasatinib, diclofenac, diflunisal, efavirenz, erlotinib,  estradiol (17-beta), 
flutamide, geftinib, gemfibrozil, glycyrrhetinic acid, glycyrrhizin, imatinib, imipramine, 
ketoconazole, lineoleic acid,  mefenamic acid, mycophenolic acid, niflumic acid, 
nilotinib, phenobarbital, phenylbutazone, phenytoin, probenecid propofol, quinidine, 
ritonavir, Sorafenib, sulfinpyrazone, valproic acid and verapamil from screening through 
follow-up period. 
 
3.2.22 Low-dose Coumadin (1 mg) is acceptable; however, doses that increase INR are not 
permitted. If an alternative to Coumadin-based anticoagulants cannot be used, the INR 
should be monitored weekly after initiation of therapy and upon discontinuation of 
INCB024360, until INR normalization. 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women of all races and ethnic groups are eligible for this trial (Table 3.3). 
 
Table 3.3. Accrual Targets by Race, Ethnicity, and Sex/Gender. 
Accrual Targets 
Ethnic Category 
Sex/Gender 
Females 
 Males 
 Total 
Hispanic or Latino 
2 
+
2 
= 
4 
Not Hispanic or Latino 
3 
+
5 
= 
8 
Ethnic Category: Total of all subjects
5 (A1) +
7 (B1) = 
12 (C1) 
Racial Category
American Indian or Alaskan Native 
 
+
1 
= 
1 
Asian 
1 
+
1 
= 
2 
Black or African American 
 
+
 
= 
 
Native Hawaiian or other Pacific Islander
 
+
 
= 
 
White 
4 
+
5 
= 
9 
Racial Category: Total of all subjects
5 (A2) +
7 (B2) = 
12 (C2)
 
(A1=A2)  
(B1=B2)  
(C1=C2)
 
 
4. REGISTRATION PROCEDURES 
 
 
Following registration, patients should begin protocol treatment within 5 days. Issues that would 
cause treatment delays should be discussed with the Principal Investigator. If a patient does not 
receive protocol therapy following registration, the patient’s registration on the study may be 
canceled. The Study Coordinator should be notified of cancellations as soon as possible. 
 
4.1 
Registration Process 
 
This study is supported by the NCI Cancer Trials Support Unit (CTSU). 
 
Prior to the recruitment of a patient for this study, investigators must be registered 
members of a Cooperative Group.    Each investigator must have an NCI investigator 
number and must maintain an “active” investigator registration status through the annual 


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26 
 
submission of a complete investigator registration packet (FDA Form 1572 with original 
signature, current CV, Supplemental Investigator Data Form with signature, and 
Financial Disclosure Form with original signature) to the Pharmaceutical Management 
Branch, CTEP, DCTD, NCI. These forms are available on the CTSU Web site (enter 
credentials at https://www.ctsu.org; then click on the Register tab) or by calling the PMB 
at 301-496-5725 Monday through Friday between 8:30 a.m. and 4:30 p.m. Eastern time. 
 
Each investigator or group of investigators at a clinical site must obtain IRB approval for 
this protocol and submit IRB approval and supporting documentation to the CTSU 
Regulatory Office before they can enroll patients. Study centers can check the status of 
their registration packets by querying the Regulatory Support System (RSS) site 
registration status page of the CTSU member web site by entering credentials at 
https://www.ctsu.org. 
 
Requirements for protocol number site registration: 
 
• 
CTSU IRB Certification 
• 
CTSU IRB/Regulatory Approval Transmittal Sheet 
• 
IRB-approved consent form (if applicable)  
• 
CTSU RT Facilities Inventory Form (If applicable) 
 
NOTE: Per NCI policy all institutions that participate on protocols with a radiation 
therapy component must participate in the Radiological Physics Center (RPC) monitoring 
program. If this form has been previously submitted to CTSU it does not need to be 
resubmitted unless updates have occurred at the RT facility. 
 
Patient enrollment will be facilitated using the Oncology Patient Enrollment Network 
(OPEN). OPEN is a web-based registration system available on a 24/7 basis.  
 
All site staff will use OPEN to enroll patients to this study.  It is integrated with the 
CTSU Enterprise System for regulatory and roster data and, upon enrollment, initializes 
the patient position in the Rave database.  
OPEN can be accessed at https://open.ctsu.org or from the OPEN tab on the CTSU 
members’ side of the website at https://www.ctsu.org. 
 
Prior to accessing OPEN site staff should verify the following: 
  
 All eligibility criteria have been met within the protocol stated timeframes. Site staff 
should use the registration forms provided on the CITN or CTSU web site as a tool to 
verify eligibility. 
 All patients have signed an appropriate consent form and HIPAA 
authorization form (if applicable).  
 
Access requirements for OPEN: 
  


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27 
 
 Site staff will need to be registered with CTEP and have a valid and active CTEP-
IAM account. This is the same account (user id and password) used for the CTSU 
members' web site.  
 To perform registrations, the site user must have been assigned the 'Registrar' role on 
the CITN roster.  
  
Note:  The OPEN system will provide the site with a printable confirmation of 
registration and treatment information.   Please print this confirmation for your records.  
  
Further instructional information is provided on the OPEN tab of the CTSU members’ 
side of the CTSU website at https://www.ctsu.org or at https://open.ctsu.org. For any 
additional questions contact the CTSU Help Desk at 1-888-823-5923 or 
ctsucontact@westat.com. 
 
Data collection for this study will be done exclusively through Medidata Rave.  Access to 
the trial in Rave is granted through the iMedidata application to all persons with the 
appropriate roles in RSS. To access iMedidata/Rave the site user must have an active 
CTEP IAM account (https://eapps-ctep.nci.nih.gov/iam).  In addition, site users that are a 
member of the CITN must have the Rave roles (Rave CRA, Read-Only, Site Investigator) 
in RSS at the enrolling site.  
 
Upon initial site registration approval for the study in RSS, all persons with Rave roles 
assigned on the CITN roster will be sent a study invitation e-mail from iMedidata.  To 
accept the invitation, site users must log into the Select Login 
(https://login.imedidata.com/selectlogin) using their CTEP-IAM user name and 
password, and click on the “accept” link in the upper right corner of the iMedidata page.  
Please note, site users will not be able to access the study in Rave until all required 
Medidata and study specific trainings are completed.  Trainings will be listed in the upper 
right pane of the iMedidata screen.   
 
Users who have not previously activated their iMedidata/Rave accounts will receive a 
separate invitation from iMedidata to activate their account.  Account activation 
instructions are located on the CTSU website, Rave tab under the Rave resource materials 
(Medidata Account Activation and Study Invitation Acceptance).  Additional information 
on iMedidata/Rave is available on the CTSU website under the Rave tab at 
www.ctsu.org/RAVE/ or by contacting the CTSU Help Desk at 1-888-823-5923 or by e-
mail at ctsucontact@westat.com.   
 
 
5. TREATMENT PLAN 
 
5.1 
Agent Administration 
 
Patients with surgically incurable stage III or IV melanoma and tissue amenable to serial 
biopsy will undergo pretreatment tumor biopsy and receive a 3-month course of 
INCB024360 administered as a twice daily continuous dosing oral regimen. The 


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MELITAC 12.1 vaccine has 3 components: 12-MP peptides, Peptide-tet, and Montanide 
ISA-51 VG vaccine adjuvant, which will be prepared together as an emulsion for 
administration. Three (3) mL of emulsion will be prepared. Two (2) mL of this emulsion will be 
administered, with 1 mL at each of 2 vaccine sites. At each site, half of each dose (0.5 mL) will 
be injected subcutaneously and half (0.5 mL) will be injected intradermally. The remaining 1 mL 
of the prepared emulsion will be discarded.  
 
On day 21, a week 3 tumor biopsy will be collected and the effects of inhibitor alone on 
the tumor microenvironment will be evaluated by comparing the pretreatment tumor 
biopsy to the day 21 tumor biopsy, assessing changes in IHC and gene signatures.  
 
Note: The biopsy on day 21 is mandatory. For patients with only one or two tumors 
approachable for biopsy, available tumor blocks from prior biopsies can serve as the 
pretreatment sample.  
 
Also on day 21, a vaccination regimen with MELITAC 12.1 multipeptide vaccine will 
begin, with vaccines administered on days 21, 28, 35, 56, 77, and 98  (Weeks 3, 4, 5, 8, 
11, and 14. MELITAC 12.1, will be administered intradermally/subcutaneously at a fixed 
dose of 2.0 ml for 6 vaccinations. On day 42, tumor will be biopsied and the effect of 
continued INCB024360 plus vaccine on the tumor microenvironment will be evaluated 
by comparing the week 3 tumor biopsy to the week 6 tumor biopsy, assessing changes in 
IHC and gene signatures.  
 
Patients will receive 3 weeks of INCB024360, followed by continued INCB024360 plus 
6 vaccinations with MELITAC 12.1. Patients who have disease progression while 
receiving anti-PD1 or anti-PDL-1 antibody treatment will be allowed to enroll and 
receive INCB024360 within 2-6 weeks of last antibody treatment administration. Patients 
enrolled within the 6 week window will be enrolled in Cohort B and administered 
INCB024360 orally at a dose of 100 mg twice daily continuously up to day 98 (3 months) 
plus vaccines. Patients who enroll in the study after confirmed disease progression on 
anti-PD1/PDL-1 after 6 weeks of receiving the last dose of antibody will be enrolled in 
Cohort A and receive 300 mg BID of INCB024360 plus vaccines.  
 
Patients that show response at 3 months will be considered for additional INCB024360.  
 
As a lead-in to ensure safety and tolerability of the combination of INCB024360 and 
MELITAC 12.1, the first 3 patients enrolled in the study will be at the dose of 300 mg bid 
staggering each patient’s enrollment by at least 2 weeks so that the first patient will 
receive 2 doses of the vaccine in combination with INCB024360 before the second 
patient starts the combination of agents. Enrollment will be halted after the first 3 patients 
are enrolled to allow for observation of any toxicity before opening further enrollment.  
The next nine patients will receive either 300 mg bid of INCB024360 or 100 mg bid  
(Table 5.1). For patient safety, if a Dose Limiting Toxicity (DLT) occurs in the first three 
patients treated at the 300 mg BID dose level of INCB024360 + MELITAC 12.1 vaccine, 
the subsequent 9 patients will be treated with the dose of either 300 mg BID or 100 mg of 
INCB024360 + MELITAC 12.1. If two DLTs occur in the first 6 patients treated at the 


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29 
 
300 mg dose of INCB024360 + MELITAC 12.1 the study will be stopped. 
 
Treatment will be administered on an outpatient basis. Reported AEs and potential risks 
are described in Section 7. Appropriate dose modifications are described in Section 6. No 
investigational or commercial agents or therapies other than those described below may 
be administered with the intent to treat the patient’s malignancy. The patient will be 
requested to maintain a medication diary of each dose of medication. The medication 
diary will be returned to clinic staff at the end of each course. 
 
Table 5.1. Agent Administration and Timing of Assessments 
Cohort 
INCB024360 
Dosing 
MELITAC 12.1 
Dosing 
Blood draws 
Tumor biopsies 
including FNA 
A 
Pts.enrolled 
>6 wks after 
failing anti-
PD-1/PDL-1 
 
300 mg po 
bid 
continuous 
for 98 days 
(3 months) 
Intradermal/subcutaneous 
Days 21, 28, 35, 56, 77, 
98 (Weeks 3, 4, 5, 8, 11, 
and 14) 
Pretreatment 
day 0 and on 
days 21, 42, 
98, and 112 
Days 0, 21, 42, and 
(optional day 112) and 
(optional when coming 
off study including for 
progression) 
B 
Pts.enrolled 
2-6 wks after 
failing anti-
PD-1/PDL-1 
100 mg po 
bid 
continuous 
for 98 days 
(3 months) 
Intradermal/subcutaneous 
Days 21, 28, 35, 56, 77, 
98 (Weeks 3, 4, 5, 8, 11, 
and 14) 
Pretreatment 
day 0 and on 
days 21, 42, 
98, and 112 
Days 0, 21, 42, and 
(optional day 112) and 
(optional when coming 
off study including for 
progression) 
Abbreviations: bid, twice per day; FNA, fine-needle aspiration; po, orally; pre-tx, pretreatment; SC, subcutaneous 
 
Enrollment will be staggered so that only 3 patients will initially be treated at the 300-mg 
bid dose in order to observe their response to the INCB024360-MELITAC 12.1 
combination. After the first patient is started on INCB024360, treatment will proceed for 
2 weeks before the second patient is started on INCB024360 monotherapy. Before the 
second patient starts the combination of INCB024360 and MELITAC 12, the first patient 
will have already received the second vaccination of MELITAC 12.1 in combination with 
INCB024360 and observed for any toxicity. The third patient will start INCB024360 
monotherapy 2 weeks after patient number 2 has received the combination of 
INCB024360 and MELITAC 12.1 and been observed for toxicities. After the first 
3 patients are treated at the 300-mg bid dose of INCB024360 in combination with the 
MELITAC 12.1 and found to tolerate the combination well, the dose of INCB024360 
will be 300 mg BID for subsequent patients. Those patients treated with anti-PD-
1/PDL1antibody who have failed therapy and enrolled in the study 6 weeks or longer 
after progression of disease will be enrolled in Cohort A and receive 300 mg BID of 
INCB024360. Patients who fail anti-PD-1/PDL-1 therapy and enroll within 2-6 weeks of 
progression of disease will receive100 mg BID in Cohort B. All other patients enrolled in 
the study will receive INCB024360 300 mg BID. 
 
A total of 12 patients will be enrolled in the study. Assignment to Cohort A or B is for 
dose assignment only. 
 


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30 
 
5.1.1 CTEP IND Agent(s): N/A 
 
5.1.2 Other Agent(s): INCB024360 
 
Combining INCB024360 with the multipeptide vaccine MELITAC 12.1 is a novel 
approach. Although no adverse findings in toxicology or safety pharmacology 
assessments have been described herein, and the most common grade 1 or 2 AEs at the 
recommended Phase-II dose (600 mg) include fatigue, nausea and vomiting, constipation, 
and anorexia; to decrease the possibility of unanticipated toxicities with the combination, 
the dose of INCB024360 in the first 3 patients treated in the study will be at the dose of 
300 mg bid.  
 
Weak cross-reactivity of INCB024360 to the human vasopressin 1a receptor, dopamine 
receptor, and carbonic anhydrase II may lead to changes in blood pressure or blood 
electrolytes. In 28-day toxicology studies, Cmax values have exceeded the IC50 for the 
IDO1 enzyme (72 nM) by up to 37-fold and the IC50 for the vasopressin 1a receptor by 
up to 4-fold (13-fold in single-dose studies) in the absence of any toxicity, so the risk of 
unintended pharmacological activity is expected to be low. 
 
5.1.3 Other Agent (s): MELITAC 12.1 
 
MELITAC 12.1 vaccine comprises 100 μg each of the 12 melanoma peptides plus 190 μg 
tetanus toxoid peptide (Peptide-tet). Peptides are synthesized under good manufacturing 
practice (GMP) conditions by PolyPeptide Group (San Diego, CA; formerly Multiple 
Peptide Systems), reconstituted, mixed, sterile-filtered, and vialed under GMP conditions 
by Merck (Germany). The 12–melanoma peptide mixture and tetanus peptide preparation 
are made as separate sterile aqueous solutions to be administered in an emulsion with 
Montanide ISA-51 VG adjuvant (1 mL), using the 2-syringe method after emulsion 
stability and quality is verified. MELITAC 12.1 stimulated immune responses with an 
excellent safety profile and with presumptive evidence of efficacy in the adjuvant setting.  
 
At this writing, the 12-MP has been administered in combination with Peptide-tet and 
GM-CSF in Montanide ISA-51 VG adjuvant to more than 200 participants enrolled in 
3 studies run through the University of Virginia Human Immune Therapy Center (HITC) 
in collaboration with other centers (Mel39, Mel43, E1602) [Slingluff 2007; Slingluff 
2009; Slingluff 2010] and 12-MP has been administered in Montanide ISA-51 VG 
adjuvant, with or without Peptide-tet in about 300 participants (Mel43, Mel44, E1602) 
[Slingluff 2010; Slingluff 2011; Slingluff 2009]. No data are available regarding the 
distribution and excretion of the vaccine preparation. In vitro studies have indicated the 
half-life of synthetic peptides in the presence of serum peptidases is short (approximately 
22 seconds) [Brinckerhoff 1999]. However, in vivo data describing the metabolism of the 
vaccine are not available.  
 
In the first 51 participants vaccinated with the 12-MP and Peptide-tet with GM-CSF in 
Montanide ISA-51 VG adjuvant, the majority of toxicities described have been of 
minimal severity. The most frequent AEs for participants receiving the 12-MP in 


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31 
 
combination with Peptide-tet include maximum grade 1 fatigue (49%), maximum grade 1 
chills (49%), maximum grade 1 headache (42%), and maximum grade 2 injection site 
reactions (69%). Other common AEs include maximum grade 1 sweating (27%), 
maximum grade 1 hyperglycemia (33%), maximum grade 1 myalgia (24%), and 
maximum grade 3 injection site reaction (27%). At this writing, at least 1 case of vitiligo 
and no cases of visual changes related to the vaccine after vaccination with the 12-MP 
and Peptide-tet administered with GM-CSF in Montanide ISA-51 VG adjuvant have been 
reported. 
 
5.1.4 Other Modalities or Procedures: N/A 
 
5.1.5 Investigational Imaging Agent Administration: N/A 
 
5.2 
Definition of Dose-Limiting Toxicity:  
 
Dose-limiting toxicities (DLTs) include all Grade 3 AEs regardless of investigator 
attribution or relatedness except for those listed below. 
Based on investigator determination the following Grade 3 toxicities can be deemed non-
DLT:  
 adverse event with a clear alternative explanation (e.g. due to disease progression) 
 transient toxicities (≤72 hours)  
 injection site reactions that are expected and do not require any surgical 
intervention or repair 
 abnormal laboratory values without associated clinically significant signs or 
symptoms    
 
There are two exceptions to the above. Grade 1 or greater ocular toxicities will be 
considered a DLT. Grade 2 LFT elevations will be considered a DLT. 
 
In the event of a DLT, it will be determined by the safety team whether both the 
INCB024360 AND the MELITAC 12.1 will be permanently discontinued.  In cases of 
vaccine injection site reaction or other vaccine related adverse events the INCB024360 
may be continued if the vaccine related adverse event continues to show improvement. 
Management and dose modifications associated with the above adverse events are further 
outlined in Section 6. 
 
5.3 
General Concomitant Medication and Supportive Care Guidelines 
 
5.3.1 INCB024360 
 
INCB024360 is neither a substrate nor an inhibitor or inducer of cytochrome P450 
enzymes. Analysis of human plasma samples indicated that INCB024360 is metabolized 
by 2 major pathways: O-glucuronidation and reduction. The identification of the 2 major 
pathways and the enzymes responsible for those pathways has enabled the refinement of 
the inclusion/exclusion criteria around concomitant medications. However for safety 
purposes, the case report form must capture the concurrent use of all other drugs, over-


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32 
 
the-counter medications, or alternative therapies. 
Hypothetically, inhibition of IDO could cause an increase in serotonin levels that could 
precipitate a cluster of AEs termed serotonin syndrome. This rare syndrome has been 
associated with some MAO inhibitors and with combinations of serotonergic drugs. 
Symptom onset is usually rapid, often occurring within minutes, and encompasses a wide 
range of clinical findings:  
o Mild symptoms may only consist of increased heart rate, shivering, sweating, dilated 
pupils, myoclonus, and over responsive reflexes.  
o Moderate symptoms include additional abnormalities such as hyperactive bowel 
sounds, high blood pressure, and hyperthermia. A temperature as high as 40°C 
(104°F) is common in moderate intoxication. Mental status changes include 
hypervigilance and agitation.  
o Severe symptoms include severe increases in heart rate and blood pressure that may 
lead to shock. In life-threatening cases, temperature may rise to above 41.1°C 
(106.0°F). Other abnormalities include metabolic acidosis, rhabdomyolysis, seizures, 
renal failure, and disseminated intravascular coagulation; these effects usually arise as 
a consequence of hyperthermia. 
 
At this writing, no laboratory test exists for serotonin syndrome; therefore diagnosis is by 
symptom observation. Management is based primarily on stopping the usage of the 
precipitating drugs, the administration of serotonin antagonists such as cyproheptadine, 
and supportive care including the control of agitation, autonomic instability, and 
hyperthermia. Additionally, those who ingest large doses serotonergic agents may benefit 
from gastrointestinal decontamination with activated charcoal if it can be administered 
within an hour of overdose. The intensity of therapy depends on the severity of 
symptoms. If the symptoms are mild, treatment may only consist of discontinuation of 
the offending medication or medications, offering supportive measures, giving 
benzodiazepines for myoclonus, and waiting for the symptoms to resolve. Moderate cases 
should have all thermal and cardiorespiratory abnormalities corrected and can benefit 
from serotonin antagonists. As mentioned above, the serotonin antagonist cyproheptadine 
is the recommended initial therapy. Additional pharmacological treatment for severe case 
includes administering atypical antipsychotic drugs with serotonin antagonist activity 
(e.g., olanzapine). Critically ill patients should receive the above therapies as well as 
sedation and/or neuromuscular paralysis. Patients who have autonomic instability such as 
low blood pressure require treatment with direct-acting sympathomimetics, such as 
epinephrine, norepinephrine, or phenylephrine. Conversely, hypertension or tachycardia 
can be treated with short-acting antihypertensive drugs such as nitroprusside or esmolol; 
longer-acting drugs such as propranolol should be avoided as they may lead to 
hypotension and shock. 
 
As mentioned above, weak cross-reactivity of INCB024360 to the human vasopressin 1a 
receptor, dopamine receptor, and carbonic anhydrase II may lead to changes in blood 
pressure or blood electrolytes. In 28-day toxicology studies, Cmax values have exceeded 
the IC50 for the IDO1 enzyme (72 nM) by up to 37-fold and the IC50 for the vasopressin 
1a receptor by up to 4-fold (13-fold in single-dose studies) in the absence of any toxicity, 
so the risk of unintended pharmacological activity is expected to be low. 


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33 
 
Studies imply that IDO1 may be a negative inhibition pathway to control autoimmune 
diseases associated with inflammation. Recent studies with the anti-CTLA-4 antibody 
ipilimumab have shown dysregulation of mucosal immunity and gastrointestinal toxicity, 
which manifests as diarrhea. For these reasons, subjects with a history of autoimmune 
disease should be excluded from participation in this study, and study participants should 
be closely monitored for signs or symptoms of developing autoimmune or inflammatory 
disease. 
 
Analysis of human plasma samples indicated that INCB024360 is metabolized by 2 
major pathways: O-glucuronidation and reduction. The O-glucuronide (M9) was formed 
by UGT1A9 and the reduced metabolite (M11) appears to be catalyzed by intestinal 
microflora.  Metabolite M11 is also further metabolized to M12, a product formed by 
oxidative cleavage catalyzed by CYPs. The identification of the 2 major pathways and 
the enzymes responsible for those pathways has enabled the refinement of the 
inclusion/exclusion criteria around concomitant medications. It should be noted that all 
three major metabolites (M9, M11 & M12) are inactive against IDO1 enzyme. 
 
Use of any UGT1A9 inhibitor including: acitretin, amitriptyline, androsterone, 
cyclosporine, dasatinib, diclofenac, diflunisal, efavirenz, erlotinib, estradiol (17-beta), 
flutamide, geftinib, gemfibrozil, glycyrrhetinic acid glycyrrhizin, imatinib, imipramine, 
ketoconazole, linoleic acid,  mefenamic acid, mycophenolic acid, niflumic acid, nilotinib, 
phenobartital, phenylbutazone, phenytoin,  and probenecid propofol, quinidine, ritonavir, 
Sorafenib, sulfinpyrazone, valproic acid, and verapamil should be avoided from 
screening through follow-up period. 
 
Low-dose Coumadin (1 mg) is acceptable; however, doses that increase INR are not 
permitted. If an alternative to Coumadin-based anticoagulants cannot be used, the INR 
should be monitored weekly after initiation of therapy and upon discontinuation of 
INCB024360, until INR normalization. 
 
5.3.2 MELITAC 12.1 
 
In several studies, the vaccine has been well tolerated. In the most recent study, in which 
the adjuvant was Montanide ISA-51 VG alone, Mel44 (n=170), 8% of patients reported 
unexpected grade 3 treatment-related AEs, plus 10% of patients with grade 3 injection-
site ulceration and 7% with grade 3 injection-site induration; the injection-site reactions 
were expected and not dose-limiting. One grade 4 toxicity was reported (hypoglycemia, 
<1%). Other common toxicities were evident for approximately 24 hours included 
fatigue, dyspnea, headache, and myalgia. Mild AEs of rigors/chills, anorexia, nausea, 
sweating, fever, and flushing were commonly experienced [Slingluff 2011]. 
 
5.4 
Duration of Therapy 
 
Patients with surgically incurable stage III or IV melanoma and tissue amenable to serial 
biopsy will receive the sequential therapy with INCB024360 alone for 3 weeks followed 


NCI Protocol #: CITN-04 
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34 
 
by continued INCB024360 plus 6 MELITAC 12.1 vaccines administered intradermally 
or subcutaneously on days 21, 28, 35, 56, 77, and 98 (weeks 3, 4, 5, 8, 11, and 14). 
 
Serial biopsies will be obtained up to 14 days before starting INCB024360, on day 21 
(before the first vaccine), and on day 42 (a week after the third vaccine). When feasible a 
biopsy will be obtained at week 16 (2 weeks after the sixth vaccination). If possible, 
tumors will be biopsied from patients coming off study, including for progression of 
disease. 
 
In the absence of treatment delays due to AE(s), treatment may continue for up to 3 
additional cycles of INCB024360 (a total of 4 cycles) after consultation with the trial 
Principal Investigator, CTEP, and the CITN, or until one of the following criteria applies: 
 
Disease progression by Response Evaluation Criteria In Solid Tumors (RECIST) or 
Immune-Related Response Criteria (irRC) 
 
Intercurrent illness that prevents further administration of treatment 
 
Unacceptable AE(s) 
 
Patient decides to withdraw from the study 
 
General or specific changes in the patient’s condition rendering the patient 
unacceptable for further treatment in the judgment of the investigator 
 
If additional cycles of INCB024360 are deemed appropriate for the patient, the 
INCB024360 will be given without the administration of the MELITAC 12.1 vaccines.  
 
Only the end of treatment biopsy will be obtained if additional cycles of INCB024360 are 
approved for each patient. 
 
In patients who are approved to receive additional cycles of INCB024360, a reduced 
volume of blood will be drawn for specific assays. (Study Calendar, footnote ***) 
 
A delay of up to 60 days between treatment cycles will be allowed. 
 
In the event of unexpected serious AEs related to either component of the combination, 
treatment of the affected participant with INCB024360 and/or MELITAC 12.1 will be 
discontinued after analysis by the DSMC, Incyte, and CITN. 
 
5.5 
Duration of Follow-up 
 
Patients will be followed for 1 year after removal from study or until death, whichever 
occurs first. Patients removed from study for unacceptable AE(s) will be followed until 
resolution or stabilization of the AE. Unacceptable toxicity is defined as any of the 
following:  
1) grade 3 or 4 adverse event requiring the patient to be removed from study 
treatment,  
2) DLT’s of grade 1 treatment related ocular toxicity, grade 2 allergic reactions,  
3) >2 cm ulceration at the vaccination site or a vaccination adverse event 
requiring antibiotic treatment, debridement or narcotic management,  


NCI Protocol #: CITN-04 
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35 
 
NOTE:  Chronic inflammatory reactions at the vaccine sites are expected to occur 
in all participants who receive Montanide ISA-51. Induration may persist for days 
to months, but is not expected to require additional therapy.  Sterile abscesses 
may occur in some participants.  These are not a basis for discontinuation of the 
vaccines.  However, if the inflammatory reactions develop significant ulceration 
of the skin (> 2 cm), then the patient would be taken off the study, however, this 
would not be considered a dose-limiting toxicity. 
4) any unexpected grade 3 or greater non-hematologic or hematologic toxicity. 
 
5.6 
Criteria for Removal from Study 
 
Patients will be removed from study when any of the criteria listed in Section 5.4 applies. 
The reason for study removal and the date the patient was removed must be documented 
in the case report form. The patient should be followed per protocol requirements. 
 
AEs will be described and coded based upon the National Cancer Institute Common 
Terminology Criteria for Adverse Events v4.0 (NCI CTCAE v4.0). Safety will be 
evaluated by assessing and chronicling treatment-related AEs. 
 
 
6. DOSING DELAYS/DOSE MODIFICATIONS 
 
All toxicity associated with prior treatment must resolve to grade 1 or less off steroid treatment 
for at least 2 weeks. Patients who have discontinued treatment for pulmonary, renal or neurologic 
toxicity or who have experienced grade 4 toxicity should not be enrolled in the study. 
 
All related toxicities will be reviewed by the protocol P.I., participating site P.I.s, CTEP and the 
CITN Coordinating Center for an indication to change the dosing schedule.  
 
The selected doses of INCB024360 and MELITAC 12.1 have been established as having 
excellent safety profiles. Dose escalation is not planned or necessary. However, when used 
together, unexpected toxicities might occur. Thus, rules for stopping will be incorporated in the 
event that dose-limiting AEs are observed.  
 
Toxicities for each agent will be monitored continuously and will be graded by the NCI CTCAE 
v4.0 with stopping rules for AEs. At the discretion of the investigators, treatment may be held for 
up to 14 days to permit the evaluation or resolution of symptoms that may be unrelated to 
treatment but may affect patient safety (e.g., influenza, minor trauma).  
 
DLT’s include all Grade 3 AEs regardless of investigator attribution or relatedness except for 
expected grade 3 injection site reactions. (section 5.5) 
Based on investigator determination the following Grade 3 toxicities can be deemed non-DLT:  
• 
adverse event with a clear alternative explanation (e.g. due to disease progression) 
• 
transient toxicities (≤72 hours)  
• 
injection site reactions that are expected and do not require any surgical intervention or 
repair 


NCI Protocol #: CITN-04 
Version Date: 27 Jan 2016 
 
36 
 
• 
abnormal laboratory values without associated clinically significant signs or symptoms    
 
There are two exceptions to the above:  Grade 1 or greater ocular toxicities will be considered a 
DLT.  Grade 2 LFT elevations will be considered a DLT. 
 
In the event of a DLT, it will be determined by the safety team whether both the INCB024360 
AND the MELITAC 12.1 will be permanently discontinued.  
 
Vitiligo will not be considered a DLT. 
 
Pages 33, 34 and 35 include tables for some of the more common AE’s including instructions for 
handling.  For any AE’s not listed in these tables, proceed in the following manner: 
Grade 1 and Grade 2:  Continue to monitor, follow and grade these adverse events. 
Grade 3:  Stop Protocol Therapy including both INCB024360 and MELITAC 12.1 
Grade 4:  Stop Protocol Therapy including both INCB024360 and MELITAC 12.1 
 
In addition, treatment will be discontinued for (a) Any DLT, (b) disease progression requiring 
other therapy, (c) noncompliance with study requirements, (d) other safety considerations in the 
judgment of the investigator, or (e) patient request.  
 
The treatment regimen will be considered safe as long as the number of participants experiencing 
a treatment-related AE (DLT) does not exceed 33%. If more than 33% of patients accrued are 
known to have experienced a treatment-related DLT, the study will be closed to further accrual, 
except that 1 treatment related DLT observed out of the first 3 patients accrued will be 
acceptable and will not result in the closing of the study.  
 
Nausea 
Management/Next Dose for  
INCB024360
Management/Next Dose for 
MELITAC 12.1 
≤ Grade 1 
No change in dose
No change in dose 
Grade 2 
No change in dose
No change in dose 
Grade 3 
Off Protocol Therapy
Off Protocol Therapy 
Grade 4 
Off protocol therapy
Off protocol therapy 
Recommended management: antiemetics
 
Vomiting 
Management/Next Dose for  
INCB024360
Management/Next Dose for 
MELITAC 12.1 
≤ Grade 1 
No change in dose
No change in dose 
Grade 2 
No change in dose
No change in dose 
Grade 3 
Off Protocol Therapy
Off Protocol Therapy 
Grade 4 
Off protocol therapy
Off protocol therapy 
Recommended management: antiemetics
 
Investigations 
(Liver Function 
Tests ALT + AST) 
Management/Next Dose for  
INCB024360
Management/Next Dose for 
MELITAC 12.1 
< Grade 1 
No change in dose
No change in dose 
Grade 1* 
No change in dose
No change in dose 


NCI Protocol #: CITN-04 
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37 
 
Investigations 
(Liver Function 
Tests ALT + AST) 
Management/Next Dose for  
INCB024360
Management/Next Dose for 
MELITAC 12.1 
Grade 2 
Off Protocol Therapy
Off Protocol Therapy 
Grade 3 or 4 
Off Protocol Therapy
Off Protocol Therapy  
*For Grade 1 LFT Elevations, increase LFT monitoring to twice weekly.
 
Diarrhea 
Management/Next Dose for  
INCB024360
Management/Next Dose for 
MELITAC 12.1 
≤ Grade 1 
No change in dose
No change in dose 
Grade 2 
No change in dose
No change in dose 
Grade 3 
Off Protocol Therapy
Off Protocol Therapy 
Grade 4 
Off protocol therapy
Off protocol therapy 
Recommended management: physician discretion
 
Neutropenia 
Management/Next Dose for
INCB024360
Management/Next Dose for
MELITAC 12.1 
≤ Grade 1 
No change in dose
No change in dose 
Grade 2 
No change in dose
No change in dose 
Grade 3 
Off Protocol Therapy
Off Protocol Therapy 
Grade 4 
Off protocol therapy
Off protocol therapy 
Recommended management: treatment of infection as appropriate
 
Thrombocytopenia 
Management/Next Dose for  
INCB024360
Management/Next Dose for 
MELITAC 12.1 
≤ Grade 1 
No change in dose
No change in dose 
Grade 2 
No change in dose
No change in dose 
Grade 3 
Off protocol therapy
Off protocol therapy 
Grade 4 
Off protocol therapy
Off protocol therapy 
Recommended management: platelet transfusions if indicated
 
Fatigue 
Management/Next Dose for  
INCB024360
Management/Next Dose for 
MELITAC 12.1 
≤ Grade 1 
No change in dose
No change in dose 
Grade 2 
No change in dose
No change in dose 
Grade 3 or Grade 4 
Off Protocol Therapy
Off Protocol Therapy 
Recommended management: physician discretion 
 
Ocular Toxicity 
Management/Next Dose for
INCB024360
Management/Next Dose for
MELITAC 12.1 
≤ Grade 1 
Off protocol therapy*
Off protocol therapy 
Grade 2 
Off protocol therapy
Off protocol therapy 
Grade 3 
Off protocol therapy
Off protocol therapy 
Grade 4 
Off protocol therapy
Off protocol therapy 
*Defined as treatment-related grade 1 ocular toxicities
 
 
 


NCI Protocol #: CITN-04 
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38 
 
Chills/fever/malaise 
following 
immunization 
Management/Next Dose for 
INCB024360
Management/Next Dose for 
MELITAC 12.1 
≤ Grade 1 
No change in dose
No change in dose 
Grade 2 
No change in dose
No change in dose 
Grade 3 
Off protocol therapy if fails to resolve 
by the next scheduled immunization
Off protocol therapy if fails to resolve 
by the next scheduled immunization
Grade 4 
Off protocol therapy
Off protocol therapy 
 
Injection site reaction 
Management/Next Dose for
INCB024360
Management/Next Dose for
MELITAC 12.1 
≤ Grade 1 
No change in dose
No change in dose 
Grade 2 
No change in dose
No change in dose  
Grade 3 
No change in dose* 
No change in dose** 
Grade 4 
Off protocol therapy
Off protocol therapy 
*See section 5.2 
** MELITAC 12.1 vaccine may be given if the grade 3 injection site reaction combined area of skin ulceration is <2 
cm  
 
6.1 
Delayed Visits for Reasons Other Than Toxicity 
 
A schedule for return visits should be established at the first visit. If a participant misses a 
vaccination, the missed treatment will be administered as soon as possible, so that the 
subsequent vaccinations are given in the appropriate intervals. Treatment may be 
continued for an additional time period, if needed. Participants who are vaccinated 
outside of the established schedule should return to the original schedule as soon as 
possible. 
 
Table 6.1 defines what constitutes a delayed visit for reasons other than toxicity, whether 
the participant should continue to be treated, and whether a protocol violation should be 
reported and recorded. The range of days is counted from the original scheduled date.  
 
Table 6.1. Delayed Visit for Reasons Other than Toxicity 
Treatment Period 
Range of Days
Participant 
Treatment
Protocol 
Deviation 
Biopsies 
Days -14 to 0*
Biopsies/Labs
 
Day 0 
 
 
 
Vaccine 1, Biopsies** 
 
 
 
Day 21 (week 3) 
 2 days
Vaccine/Labs
No 
   
 3 to 7 days 
Vaccine/Labs
Yes 
 
 8 or more days 
Labs
Yes 
Vaccines 2  
 
 
 
Day 28 (week 4) 
 2 days
Vaccine/ /Biopsy
No 
   
 3 to 7 days 
Vaccine/ /Biopsy
Yes 
 
 8 or more days 
Labs
Yes 
Vaccine 3 
 
 
 
Day 35 (week 5) 
 2 days
Vaccine/
No 


NCI Protocol #: CITN-04 
Version Date: 27 Jan 2016 
 
39 
 
Treatment Period 
Range of Days
Participant 
Treatment
Protocol 
Deviation 
   
 3 to 7 days 
Vaccine/
Yes 
 
 8 or more days 
Labs
Yes 
Biopsies** 
 
 
 
Day 42 (week 6) 
 2 days
Labs
No 
   
 3 to 7 days 
Labs
Yes 
 
 8 or more days 
Labs
Yes 
Vaccines 4–6**
 
 
 
Days 56, 77, 98  
 2 days
Vaccine/Labs***
No 
 (weeks 8, 11, 14) 
 3 to 7 days
Vaccine/Labs***
Yes 
 
 8 or more days 
Labs
Yes 
Biopsies (Optional)**  
 
 
 
Day 112 (Week 16) 
 7 days
Labs
No 
 
 8 to 14 days 
Labs
Yes 
 
 15 or more days 
Labs
Yes 
Follow-up 
 
 
 
Week 26 
 14 days
Scans/Labs
No 
 
 15 days or more 
Scans/Labs
Yes 
* The pretreatment biopsies should be performed before the first treatment with INCB024360, within 
14 days of that start date. For patients with only one or two tumors approachable for biopsy, available 
tumor blocks from prior biopsies can serve as the pretreatment sample provided at least 20 unstained 
slides are available. 
**A participant will be taken off protocol treatment if more than 1 vaccination is delayed [ 3 to 7 days] 
during the treatment period. 
 
 
7. ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial. The 
following list of AEs (Section 7.1) and the characteristics of an observed AE (Section 7.2) will 
determine whether the event requires expedited reporting (via CTEP-AERS) in addition to 
routine reporting. 
 
7.1 
Comprehensive Adverse Events and Potential Risks List(s) (CAEPRs)  
 
7.1.1 CAEPRs for CTEP IND Agent(s): N/A 
 
7.1.2 CAEPRs for INCB024360 (NSC 766086) 
 
The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of 
reported and/or potential adverse events (AE) associated with an agent using a uniform 
presentation of events by body system. In addition to the comprehensive list, a subset, the 
Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and 
is identified with bold and italicized text. This subset of AEs (SPEER) is a list of events that are 
protocol specific exceptions to expedited reporting to NCI via CTEP-AERS (except as noted 
below).  Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting Requirements'  


NCI Protocol #: CITN-04 
Version Date: 27 Jan 2016 
 
40 
 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for 
further clarification.  The CAEPR does not provide frequency data; refer to the Investigator's 
Brochure for this information. Below is the CAEPR for INCB024360. 
 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to 
the AE in the SPEER.  If this CAEPR is part of a combination protocol using multiple 
investigational agents and has an AE listed on different SPEERs, use the lower of the grades to 
determine if expedited reporting is required. 
 
Adverse Events with Possible                         
Relationship to INCB024360                          
(CTCAE 4.0 Term) 
Version 1.1, October 15, 2015 
 
Specific Protocol Exceptions 
to   Expedited Reporting 
(SPEER) 
 
GASTROINTESTINAL DISORDERS 
 
Abdominal distension 
 
Abdominal Pain 
Abdominal pain (Gr 2)
Constipation 
Constipation (Gr 2) 
Diarrhea 
Diarrhea (Gr 2) 
Nausea 
Nausea (Gr 2) 
Vomiting 
Vomiting (Gr 2) 
GENERAL DISORDERS AND ADMINISTRATION 
SITE CONDITIONS 
 
Edema limbs 
Edema limbs (Gr 2) 
Fatigue 
Fatigue (Gr 2) 
Fever 
Fever (Gr 1) 
Pain 
Pain (Gr 2) 
IMMUNE SYSTEM DISORDERS 
 
Autoimmune disorder2 
 
INVESTIGATIONS 
 
Alanine aminotransferase increased 
Alanine aminotransferase 
increased (Gr 1) 
Aspartate aminotransferase increased 
Aspartate aminotransferase 
increased (Gr 1) 
Weight loss 
Weight loss (Gr 2) 
METABOLISM AND NUTRITION DISORDERS 
 


NCI Protocol #: CITN-04 
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41 
 
Anorexia 
Anorexia (Gr 2) 
Dehydration 
Dehydration (Gr 2) 
Hypokalemia 
Hypokalemia (Gr 2) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE 
DISORDERS  
 
Arthralgia 
 
Back Pain 
Back pain (Gr 2) 
NERVOUS SYSTEM DISORDERS 
 
Dizziness 
 
Dysgeusia 
 
Headache 
 
Peripheral sensory neuropathy 
Peripheral sensory 
neuropathy (Gr 2) 
PSYCHIATRIC DISORDERS 
 
Insomnia 
 
RESPIRATORY, THORACIC AND MEDIASTINAL 
DISORDERS 
 
Cough 
Cough (Gr 1) 
Dyspnea 
Dyspnea (Gr 1) 
Hypoxia 
 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
 
Rash maculo-papular 
Rash maculo-papular (GR 2) 
 
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be 
distributed to all Principal Investigators at the time of revision.  The current version can be 
obtained by contacting PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, 
the protocol and the agent should be included in the e-mail. 
 
2INCB024360 can result in severe and potentially fatal immune-mediated adverse events.  These 
include (but are not limited to) autoimmune hepatitis and autoimmune hypophysitis.  
 
Adverse events reported on INCB024360 trials, but for which there is insufficient eveidence 
to suggest that there was a reasonable possibility that INCB024360 caused the adverse 
event: 
 
Investigations – GGT increased 


NCI Protocol #: CITN-04 
Version Date: 27 Jan 2016 
 
42 
 
Metabolism and nutrition disorders – Hypernatremia 
Respiratory, thoracic and mediastinal disorders – Pneumonitis 
Vascular disorders - Hypertension 
 
Note: INCB024360 in combination with other agents could cause an exacerbation of any adverse 
event currently known to be caused by the other agent, or the combination may result in events 
never previously associated with either agent. 
 
No AEs have been reported consistent with the serotonin syndrome. 
 
7.1.2.1 Suspected, Unexpected Serious Adverse Reactions  
 
A single suspected, unexpected, serious adverse reaction (SUSAR) reported in any ongoing 
clinical study of INCB024360 up to the clinical cutoff date for data inclusion in the Investigator 
Brochure (03 December 2013) is listed in Table 7.1.2.1. 
 
Table 7.1.2.1. Adverse Events Occurring in ≥20% of Subjects  
MedDRA System 
Organ Class  
Worst Seriousness 
Criteria  
Preferred Term  
Study Drug  
Injury, poisoning, and 
procedural complications  
Hospitalized  
Radiation pneumonitis  
INCB024360  
General disorders and 
administration site 
conditions  
Hospitalized  
Pyrexia  
INCB024360  
General disorders and 
administration site 
conditions  
Hospitalized  
Pyrexia  
INCB024360  
General disorders and 
administration site 
conditions  
Hospitalized  
Abdominal pain  
INCB024360  
Infections and 
infestations  
Hospitalized  
Pneumonia  
INCB024360  
Infections and 
infestations  
Hospitalized  
Colitis  
INCB024360+ 
ipilimumab  
Infections and 
infestations  
Medically significant  
Infection  
INCB024360 + 
ipilimumab  
Investigations  
Medically significant, 
hospitalized  
Alanine 
aminotransferase 
increased  
INCB024360 + 
ipilimumab  
Investigations  
Medically significant, 
hospitalized  
Aspartate 
aminotransferase 
increased  
INCB024360 + 
ipilimumab  
Investigations  
Medically significant  
Alanine 
aminotransferase 
increased  
INCB024360 + 
ipilimumab  
Investigations  
Medically significant  
Aspartate 
aminotransferase 
increased  
INCB024360 + 
ipilimumab  
Abbreviations: MedDRA, Medical Dictionary for Regulatory Activities. 
 


NCI Protocol #: CITN-04 
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43 
 
7.1.3 CAEPRs for MELITAC 12.1  
 
7.1.3.1 12-MP and Peptide-tet vaccine  
There is no reason to expect direct toxicity of the melanoma peptides, as they are not 
directly cytotoxic in vitro. On the other hand, because some of these peptides are 
identical or similar to a portion of a normal protein, risks of autoimmunity in humans are 
important to evaluate. Because no murine system adequately models the human immune 
response to these peptides, the most meaningful evaluation of this peptide vaccine 
mixture is in participants with melanoma. We will focus this study on participants with 
advanced melanoma (i.e., unresectable stage III or stage IV melanoma). These 
individuals face a high risk (>90%) of premature death, and the anticipated risk of short-
term or long-term toxicity of this vaccine preparation is minimal (Table 7.1.4.1), although 
it might delay or decrease the risk of morbidity and mortality due to melanoma in these 
participants. The potential implications of autoimmunity against cells of melanocytic 
lineage are illustrated by reported cases of vitiligo occurring coincident with regressions 
of melanoma. Most of these are limited, often occurring in skin surrounding the 
regressing melanoma, but occasionally occurring systemically. While pathogenesis of 
this phenomenon can only be hypothesized, it is reasonable to consider this a worst-case 
scenario.  
 
**All participants should be closely observed for AEs for at least 20 minutes after 
each vaccination. Any time thereafter, participants should report any AEs to their 
treating physician. 
 
Table 7.1.4.1. Toxicity Data for Mel 39 (Arm B) and Mel 43 (Arms B and D) 
Description 
N
%
Grade, n 
1
2
3 
Overall number of Participants
51
100
1
35 
15 
Allergy/Immunology 
6
12
5
1 
. 
Allergic rhinitis 
4
8
3
1 
. 
Autoimmune reaction 
2
4
2
. 
. 
Blood/Bone Marrow 
8
16
7
1 
. 
Hemoglobin 
4
8
4
. 
. 
Hemoglobin 
2
4
2
. 
. 
Lymphopenia 
2
4
1
1 
. 
Cardiovascular (General) 
2
4
2
. 
. 
Edema 
2
4
2
. 
. 
Constitutional Symptoms 
43
84
27
12 
4 
Constitutional symptoms, other
1
2
1
. 
. 
Fatigue (lethargy, malaise, asthenia)
42
82
27
11 
4 
Fever (in the absence of neutropenia)
14
27
11
3 
. 
Rigors, chills 
27
53
25
2 
. 
Sweating (diaphoresis) 
16
31
16
. 
. 
Dermatology/Skin 
51
100
3
35 
13 
Alopecia 
1
2
1
. 
. 
Bruising 
1
2
1
. 
. 
Dermatology/Skin, other 
4
8
3
1 
. 
Flushing 
10
20
10
. 
. 


NCI Protocol #: CITN-04 
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44 
 
Description 
N
%
Grade, n 
1
2
3 
Hand-foot syndrome 
1
2
1
. 
. 
Injection site reaction 
51
100
3
35 
13 
Pigmentation changes (e.g., vitiligo)
1
2
1
. 
. 
Pruritus 
3
6
3
. 
. 
Rash 
2
4
1
1 
. 
Rash/desquamation 
1
2
1
. 
. 
Wound, noninfectious 
4
8
4
. 
. 
Endocrine 
2
4
 
. 
. 
Endocrine, other 
1
2
1
. 
. 
Hyperthyroidism 
1
2
1
. 
. 
Gastrointestinal 
26
51
23
3 
. 
Anorexia 
11
22
9
2 
. 
Constipation 
1
2
1
. 
 
Diarrhea patients without colostomy
5
10
5
. 
. 
Flatulence 
1
2
1
. 
. 
Gastrointestinal, other 
1
2
1
. 
. 
Heartburn 
2
4
2
. 
. 
Mouth dryness  
1
2
1
. 
. 
Mucositis, oral cavity 
2
4
2
. 
. 
Nausea 
14
27
12
2 
. 
Stomatitis/pharyngitis 
3
6
3
. 
. 
Vomiting 
3
6
3
. 
. 
Hemorrhage 
2
4
2
. 
. 
Hemorrhage pulmonary, nose 
1
2
1
. 
. 
Rectal bleeding/hematochezia 
1
2
1
. 
. 
Hepatic 
7
14
6
1 
. 
Alkaline phosphatase 
4
8
4
. 
. 
SGOT (AST) 
3
6
3
. 
. 
SGPT (ALT) 
2
4
1
1 
. 
Infection/Febrile Neutropenia
2
4
.
2 
. 
Infection, cellulitis 
1
2
.
1 
. 
Infection without neutropenia 
1
2
.
1 
. 
Lymphatics 
6
12
6
. 
. 
Edema: limb 
4
8
4
. 
. 
Lymphatics 
1
2
1
. 
. 
Lymphatics, other 
3
6
3
. 
. 
Metabolic/Laboratory 
27
53
21
6 
. 
Creatinine 
2
4
.
2 
. 
GFR 
1
2
1
. 
. 
Hyperglycemia 
19
37
16
3 
. 
Hyperkalemia 
1
2
1
. 
. 
Hypernatremia 
1
2
1
. 
. 
Hypocalcemia 
2
4
2
. 
. 
Hypoglycemia 
4
8
4
. 
. 
Hypokalemia 
2
4
2
. 
. 
Hypomagnesemia 
3
6
3
. 
. 
Hyponatremia 
1
2
1
. 
. 
Hypophosphatemia 
1
2
.
1 
. 


NCI Protocol #: CITN-04 
Version Date: 27 Jan 2016 
 
45 
 
Description 
N
%
Grade, n 
1
2
3 
Metabolic/Lab, other 
1
2
1
. 
. 
SGPT (ALT) 
1
2
1
. 
. 
Musculoskeletal 
5
10
4
1 
. 
Musculoskeletal, other 
5
10
4
1 
. 
Neurology 
13
25
10
3 
. 
CNS ischemia 
1
2
.
1 
. 
Confusion 
1
2
1
. 
. 
Dizziness 
5
10
4
1 
. 
Dizziness/lightheadedness 
3
6
3
. 
. 
Memory loss 
1
2
1
. 
. 
Mood alteration, agitation 
1
2
1
. 
. 
Mood alteration, anxiety 
1
2
.
1 
. 
Mood alteration, depression 
1
2
1
. 
. 
Neuropathy, sensory 
2
4
2
. 
. 
Syncope (fainting) 
2
4
2
. 
. 
Ocular/Visual 
3
6
3
. 
. 
Dry eye 
1
2
1
. 
. 
Ocular, other 
2
4
2
. 
. 
Ocular surface disease 
1
2
1
. 
. 
Pain 
40
78
27
13 
. 
Arthralgia (joint pain) 
17
33
14
3 
. 
Headache 
24
47
21
3 
. 
Myalgia (muscle pain) 
24
47
15
9 
. 
Pain, abdomen NOS 
1
2
1
. 
. 
Pain, back 
3
6
3
. 
. 
Pain extremity, limb 
2
4
2
. 
. 
Pain, throat/pharynx/larynx 
1
2
1
. 
. 
Pain, other 
5
10
4
1 
. 
Pulmonary 
12
24
6
4 
2 
Cough 
7
14
5
2 
. 
Dyspnea (shortness of breath) 
6
12
3
1 
2 
Pneumonitis 
1
2
.
1 
. 
Pulmonary, other 
2
4
2
. 
. 
Voice changes/strider/larynx 
3
6
3
. 
. 
Renal/Genitourinary 
3
6
3
. 
. 
Creatinine 
2
4
2
. 
. 
Renal, other 
1
2
1
. 
. 
Sexual/Reproductive Function
1
2
.
1 
. 
Vaginitis 
1
2
.
1 
. 
 
 
 
Montanide ISA-51 VG 
 
The adjuvant Montanide ISA-51 VG has been used in a number of clinical trials with 
little toxicity observed. The possible side effects of receiving Montanide ISA-51 VG 
adjuvant include local vaccine-site skin reaction. In addition, a theoretical risk exists for 
anaphylaxis in response to one of the ingredients in Montanide ISA-51 VG. Such a 


NCI Protocol #: CITN-04 
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46 
 
reaction might include hives, rash, generalized swelling of the body, hypotension, 
dyspnea, and abdominal pain, and possibly death.  
 
7.1.4 CAEPRs for Commercial Agent: N/A 
 
7.1.5 Adverse Event List(s) for CIP (e.g., Study-Specific) Commercial Imaging Agents: N/A 
 
7.2 
Adverse Event Characteristics  
 
 CTCAE term (AE description) and grade: The descriptions and grading scales 
found in the revised NCI Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0 will be utilized for AE reporting. All appropriate treatment 
areas should have access to a copy of the CTCAE version 4.0. A copy of the CTCAE 
version 4.0 can be downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
 For expedited reporting purposes only:  
- 
AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed in the 
SPEER column, Section 7.1.1) should be reported through CTEP-AERS only if the 
grade is above the grade provided in the SPEER. 
- 
Other AEs for the protocol that do not require expedited reporting are outlined in 
Section 7.3.4. 
 
 Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 
7.3 
Expedited Adverse Event Reporting 
 
7.3.1 Expedited AE reporting for this study must use CTEP-AERS (CTEP Adverse Event 
Reporting System), accessed via the CTEP Web site (http://ctep.cancer.gov). The 
reporting procedures to be followed are presented in the “NCI Guidelines for 
Investigators: Adverse Event Reporting Requirements for DCTD (CTEP and CIP) and 
DCP INDs and IDEs” which can be downloaded from the CTEP Web site 
(http://ctep.cancer.gov). These requirements are briefly outlined in the tables below 
(Section 7.3.3). 
 
In the rare occurrence when Internet connectivity is lost, a 24-hour notification is to be 
made to CTEP by telephone at 301-897-7497. Once Internet connectivity is restored, the 
24-hour notification phoned in must be entered electronically into CTEP-AERS by the 
original submitter at the site. 
 


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47 
 
7.3.2 CTEP-AERS is programmed for automatic electronic distribution of reports to the 
following individuals: Study Coordinator of the Lead Organization, Principal 
Investigator, and the local treating physician. CTEP-AERS provides a copy feature for 
other e-mail recipients.  
 
7.3.3 Expedited Reporting Guidelines 
 
Use the NCI protocol number and the protocol-specific patient ID assigned during trial 
registration on all reports. 
 
Note: A death on study requires both routine and expedited reporting regardless of 
causality, unless as noted below. Attribution to treatment or other cause must be provided. 
 
Death due to progressive disease should be reported as Grade 5 “Neoplasms benign, 
malignant and unspecified (incl cysts and polyps) - Other (Progressive Disease)” 
under the system organ class (SOC) of the same name. Evidence that the death was a 
manifestation of underlying disease (e.g., radiological changes suggesting tumor growth 
or progression: clinical deterioration associated with a disease process) should be 
submitted.  
 
Early Phase 2 Studies: Expedited Reporting Requirements for Adverse Events that Occur 
on Studies under an IND/IDE within 30 Days of the Last Administration of the 
Investigational Agent/Intervention 1, 2 
FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312) 
NOTE: Investigators MUST immediately report to the sponsor (NCI) ANY Serious Adverse Events, whether or not 
they are considered related to the investigational agent(s)/intervention (21 CFR 312.64) 
An adverse event is considered serious if it results in ANY of the following outcomes:  
1) 
Death 
2) 
A life-threatening adverse event  
3) 
An adverse event that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 
hours  
4) 
A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions  
5) 
A congenital anomaly/birth defect.  
6) 
Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization 
may be considered serious when, based upon medical judgment, they may jeopardize the patient or 
subject and may require medical or surgical intervention to prevent one of the outcomes listed in this 
definition. (FDA, 21 CFR 312.32; ICH E2A and ICH E6). 
ALL SERIOUS adverse events that meet the above criteria MUST be immediately reported to the NCI via CTEP-
AERS within the timeframes detailed in the table below. 
Hospitalization 
Grade 1 and Grade 2 Timeframes 
Grade 3–5 
Timeframes
Resulting in 
Hospitalization  
≥ 24 hrs 
10 Calendar Days 
24-Hour 5 Calendar 
Days 
Not resulting in 
Hospitalization  
≥ 24 hrs 
Not required 


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48 
 
NOTE: Protocol specific exceptions to expedited reporting of serious adverse events are found in the Specific 
Protocol Exceptions to Expedited Reporting (SPEER) portion of the CAEPR. 
Expedited AE reporting timelines are defined as: 
o 
“24-Hour; 5 Calendar Days” - The AE must initially be reported via CTEP-AERS within 24 hours of learning 
of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour report. 
o 
“10 Calendar Days” - A complete expedited report on the AE must be submitted within 10 calendar days of 
learning of the AE. 
1Serious adverse events that occur more than 30 days after the last administration of investigational 
agent/intervention and have an attribution of possible, probable, or definite require reporting as follows:  
Expedited 24-hour notification followed by complete report within 5 calendar days for: 
 
All Grade 3, 4, and Grade 5 AEs 
Expedited 10 calendar day reports for: 
 
Grade 2 AEs resulting in hospitalization or prolongation of hospitalization 
2For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half-lives, 
rounded UP to the nearest whole day, after the agent/intervention was last administered. Footnote “1” above 
applies after this reporting period. 
Effective Date: May 5, 2011 
 
7.3.4 Additional Protocol-Specific Expedited Adverse Event Reporting Exclusions: N/A 
 
7.4 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions. AEs reported 
through CTEP-AERS must also be reported in routine study data submissions. 
7.5 
Secondary Malignancy 
 
A secondary malignancy is a cancer caused by treatment for a previous malignancy (e.g., 
treatment with investigational agent/intervention, radiation or chemotherapy). A 
secondary malignancy is not considered a metastasis of the initial neoplasm.  
 
CTEP requires all secondary malignancies that occur following treatment with an agent 
under an NCI IND/IDE be reported via CTEP-AERS. Three options are available to 
describe the event:  
 Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia 
[AML])  
 Myelodysplastic syndrome (MDS)  
 Treatment-related secondary malignancy  
 
Any malignancy possibly related to cancer treatment (including AML/MDS) should also 
be reported via the routine reporting mechanisms outlined in each protocol.  
 
7.6 
Second Malignancy 
 
A second malignancy is one unrelated to the treatment of a prior malignancy (and is 
NOT a metastasis from the initial malignancy). Second malignancies require ONLY 
routine reporting via CDUS unless otherwise specified.  
 


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49 
 
8. PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational agent, vaccine 
and adjuvant administered in this study can be found in Section 7.1. 
 
8.1 
CTEP IND Agent(s): N/A  
 
8.2 
INCB024360, Inhibitor of Indoleamine 2,3-dioxygenase (IDO, NSC # 766086)  
 
8.2.1 Product Description 
 
The INCB024360 drug substance is a white to off-white powder. INCB024360 is 
formulated as an immediate-release tablet in 3 strengths (25 mg, 100 mg, and 300 mg). 
The tablets contain the active drug (INCB024360) along with commonly used 
compendial excipients. The chemical name of INCB024360 is (Z)-N-(3-Bromo-4-
fluorophenyl)-N′-hydroxy-4-(2-(sulfamoylamino) ethylamino)-1,2,5-oxadiazole-3-
carboximidamide. INCB024360 has a molecular formula of C11H13BrFN7O4S and a 
molecular weight of 438.23. 
 
The predicted clinical plasma Cmax is ≤10 μM for a pharmacologically active dose of 
INCB024360. 
 
8.2.2 Storage Conditions 
 
The INCB024360 drug product should be stored at ambient conditions (15°–30°C or 
59°-86°F). 
 
8.2.3 Stability 
 
The INCB024360 drug substance has been shown to be stable for at least 6 months at 
accelerated ICH conditions of 40°C/75% relative humidity and at least 24 months at 
long-term storage conditions of 25°C/60% relative humidity. INCB024360 tablets (25 mg 
and 100 mg) are stable for at least 6 months at accelerated ICH conditions and for at least 
12 months at long-term storage conditions. INCB024360 300-mg tablets are stable for at 
least 1 month at accelerated ICH conditions and long-term storage conditions. Stability of 
INCB024360 drug substance and tablets will be monitored to support ongoing clinical 
trials. 
 
8.2.4 Route of Administration 
 
Administration of INCB024360 is by mouth twice daily, taken on an empty stomach at 
least one hour prior or two hours after a meal.    
 


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50 
 
8.2.5 Overdosage 
 
No clinical experience with overdosage of INCB024360 has been reported. Treatment of 
overdosage should consist of general supportive measures. 
 
8.2.6 Intended Indications 
 
The intended indication for INCB024360 is for the treatment of malignant diseases. 
 
8.2.7 Contraindications 
 
INCB024360 is contraindicated in subjects with clinically significant hypersensitivity to 
any component of its formulation.  
 
8.2.8 Carcinogenesis, Mutagenesis, and Impairment of Fertility Studies 
 
INCB024360 was not genotoxic in a non-GLP (good laboratory practice) Salmonella 
Plate Incorporation Assay. Fertility studies and carcinogenicity studies have not been 
performed.  
 
8.2.9 Usage in Pregnancy 
 
INCB024360 should not be used by pregnant women. Studies to evaluate the potential for 
embryo toxicity and teratogenicity have not been performed.  
 
8.2.10 Nursing Mothers 
 
It is not known whether INCB024360 passes into human milk. INCB024360 should not 
be taken by nursing mothers. 
 
8.2.11 Availability 
 
INCB024360 is an investigational agent supplied to investigators by Incyte Corporation 
(Wilmington, DE). 
Incyte Corporation will provide a limited stock supply of INCB024360 to each institution 
participating in protocol CITN04 prior to the first participant being enrolled. 
 
8.2.12 Potential Drug Interactions: 
 
Metabolism of INCB024360 occurs via UGT1A9 isoenzymes and via glucuronidation.  
Concomitant use of potent UGT1A9 inducers or inhibitors are prohibited. In vitro data 
suggests INCB024360 is a substrate and weak inhibitor of P-glycoprotein.  Interaction 
studies have not been performed, but INCB024360 is believed to have low potential to 
cause drug-drug interactions through P-gp interaction. INCB024360 may cause an 
increase in serotonin levels which has the potential to precipitate serotonin syndrome 
when administered in combination with monoamine oxidase (MAO) inhibitors or 


NCI Protocol #: CITN-04 
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51 
 
serotonergic agents. Concomitant use of MAO inhibitors is prohibited.   
 
Use of coumadin is discouraged.  Low-dose Coumadin (1 mg) is acceptable; however, 
doses that increase the INR are discouraged and will require dose modification. If an 
alternative to coumarin-based anticoagulants cannot be used, dose adjustment of the 
Coumadin may be needed. Based on the observed magnitude of epacadostat 
(INCB024360)/warfarin PK interaction and PK/PD modeling results, for an epacadostat 
dose of 300 mg BID, the dose of warfarin should be reduced by approximately one-third 
after initiation of epacadostat (INCB024360) administration based on approximately 30% 
to 40% reduction in S- and R-warfarin oral clearance values. Close INR monitoring is 
recommended for patients on a stable dose of warfarin who are starting treatment with 
epacadostat. Based on PK/PD modeling, recommendations for warfarin dose 
modifications for subjects receiving other epacadostat doses, are summarized in the table 
below based on the INR prior to starting epacadostat. Refer to protocol eligibility criteria 
for additional information. 
 
Stable Baseline 
INR 
Epacadostat (INCB024360) Dose 
< 100 mg BID 
200 mg BID 
300 mg BID 
INR < 
Close INR 
monitoring 
Close INR monitoring 
Reduce warfarin by  
~33% and monitor INR 
INR > 
Close INR 
monitoring 
Reduce warfarin by 20- 
25% and monitor INR 
Reduce warfarin by ~ 
33% and monitor INR 
 
 
8.3 
MELITAC 12.1 
 
8.3.1 Product Description 
 
The MELITAC 12.1 vaccine has 3 components: 12-MP peptides, Peptide-tet, and 
Montanide ISA-51 VG vaccine adjuvant, which will be prepared together as an emulsion 
for administration.  
 
12-MP is a multipeptide mixture containing 12 class I MHC-restricted peptides derived 
from melanocyte differentiation proteins (MDP) and cancer testis antigens (CTA). The 
12 peptides included in the vaccine are restricted to HLA-A1, -A2, or -A3 
(Table 8.3.1.1). 
 
Table 8.3.1.1. 12-MP Peptides 
Allele 
Sequence
Epitope
HLA-A1 
DAEKSDICTDEY
Tyrosinase 240-251 * 
SSDYVIPIGTY
Tyrosinase 146-56 
EADPTGHSY
MAGE-A1 161-169 
EVDPIGHLY
MAGE-A3 168-176 
HLA-A2 
YMDGTMSQV
Tyrosinase 369-377  
IMDQVPFSV
gp100 209-217 # 
YLEPGPVTA
gp100 280-288 


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52 
 
GLYDGMEHL
MAGE-A10 254-262 
HLA-A3 
ALLAVGATK
gp100 17-25 
LIYRRRLMK
gp100 614-622 
SLFRAVITK
MAGE-A1 96-104 
ASGPGGGAPR
NY-ESO-1 53-62 
* 
(substitution of S for C at residue 244) 
 (post-translational change of N to D at residue 371) 
# 
(209-2M, substitution of M for T at position 210) 
Peptide-tet is a slightly modified form of a 15 residue peptide p2 of tetanus toxoid 
(QYIKANSKFIGITEL), representing amino acid residues 830-844. This peptide binds to 
HLA-DR1, DRw15(2), DRw18(3), DR4Dw4, DRw11(5), DRw13(w6), DR7, DRw8, 
DR9, DRw52a, and DRw52b, which account for 80–90% of the patient population. 
Because glutamine (Q) at the N-terminus can cyclize, giving rise to a slight change in 
molecular structure, we have prepared this peptide as a 16-residue species, where an 
alanine residue (A) has been added to the N-terminus. Thus, the sequence of the tetanus 
peptide used is AQYIKANSKFIGITEL (Table 8.3.1.2). 
 
Table 8.3.1.2. Tetanus Toxoid-derived Helper Peptide 
Allele 
Sequence 
Epitope 
Binds to multiple class II alleles 
AQYIKANSKFIGITEL 
p2830-844** 
All peptide preparations are lyophilized and stored in sterile vials sealed with a rubber 
stopper. The peptides are stored at ≤-70oC and protected from light. Each lot of peptide 
has met the lot release criteria for identity, purity, trifluoroacetic acid (TFA) content, 
potency, pyrogenicity, general safety, and sterility. Human studies investigating the 
pharmacokinetics and metabolism of the 12-MP and Peptide-tet vaccines have not been 
conducted. 
 
8.3.2 Agent Supply 
 
8.3.2.1 12-MP 
The 12-MP mixture is supplied in sterile single-use vials of lyophilized white powder 
containing a mixture of the 12 peptides and salts to buffer the solution once reconstituted. 
Each vial of 12-MP contains 150 μg each of the 12 melanoma peptides. All peptides are 
synthesized under GMP conditions by Multiple Peptide Systems (San Diego, CA). The 
peptides were vialed under GMP conditions by Clinalfa Line (Merck Biosciences AG, 
Laufelfingen, Switzerland). These 12-MP vials are provided by the University of 
Virginia. The University of Virginia will be the distributor of the agent to the research 
sites. 
 
8.3.2.2 Peptide-tet  
Peptide-tet is supplied in sterile single-use vials of white powder. Each vial of Peptide-tet 
contains 300 μg of tetanus peptide. The peptide was synthesized under GMP conditions 
by Multiple Peptide Systems (San Diego, CA). The peptides were vialed under GMP 
conditions by Clinalfa Line (Merck Biosciences AG, Laufelfingen, Switzerland). The 
agent is provided by the University of Virginia. The University of Virginia will be the 
distributor of the agent to the research sites. 


NCI Protocol #: CITN-04 
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53 
 
8.3.3 Solution Preparation 
 
All vaccines are to be made in a certified, sterile laminar flow hood. The emulsion will be 
prepared as 3-mL quantities: 2 mL of this emulsion will be administered, with 1 mL of 
emulsion administered at each of 2 vaccine sites. At each site, half of each dose (0.5 mL) 
will be injected subcutaneously and half (0.5 mL) will be injected intradermally. The 
remaining 1 mL of the prepared emulsion is to be discarded.  
 
The 2-mL dose of each vaccine contains 100 μg each of the 12 peptides listed in Table 1 
of Appendix E and 200 μg of tetanus peptide (Table 2 of Appendix E), emulsified in 
1 mL of Montanide ISA-51 VG adjuvant. See Appendix E for complete solution 
preparation instructions. 
 
8.3.4 Storage Requirements 
 
Vials of lyophilized peptides should be stored at ≤-70°C and protected from light. All 
peptide preparations are lyophilized and stored in sterile vials sealed with a rubber 
stopper. Each lot of peptide has met the lot release criteria for identity, purity, TFA 
content, potency, pyrogenicity, general safety, and sterility.  
 
Ideally, vials of the 12-MP and Peptide-tet should be thawed just before preparing a 
vaccine (i.e., thawed at room temperature for 1–2 minutes before reconstitution). 
Repeated freeze-thaws should be avoided. Vials that are frozen and thawed >2 times 
should not be used. Vials should not be left at room temperature for more than 24 hours. 
 
8.3.5 Stability 
 
All peptide preparations will be assayed for stability at months 3, 6, 12, 24, and 36. High-
performance liquid chromatography will be performed to confirm purity and sterility 
testing will be conducted in accord with FDA guidelines in 21 CFR, part 610.12. In 
addition, 1 vial of peptide will be submitted to either the Clinical Microbiology 
Laboratory at the University of Virginia or Microbiology Research Associates, Inc. 
(Acton, MA).  
 
MELITAC 12.1 vaccine comprises 100 μg each of the 12-MP mixture plus 190 μg of 
Peptide-tet. Peptides are synthesized under GMP conditions by PolyPeptide Group 
(formerly Multiple Peptide Systems), reconstituted, mixed, sterile-filtered, and vialed 
under GMP conditions by Merck. The 12–melanoma peptide mixture and tetanus peptide 
preparation are made as separate sterile aqueous solutions to be administered in an 
emulsion with Montanide ISA-51 VG adjuvant (1 mL), using the 2-syringe method after 
emulsion stability and quality is verified.  
After a peptide-based vaccine is mixed, the prepared vaccine should be refrigerated until 
just before administration. Ideally, the vaccine should be administered within 1–2 hours 
after mixing. The vaccine must be administered within 4 hours of mixing. If the vaccine 
is not administered within 4 hours of mixing, it should be discarded. 
 


NCI Protocol #: CITN-04 
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54 
 
8.3.6 Route of Administration 
 
All participants will receive 6 vaccination times over 12 weeks with MELITAC 12.1 
(100 μg of each of 12 Class I MHC restricted melanoma peptides) (Table 1 of 
Appendix E) and 200 μg of a tetanus helper peptide (Table 2 of Appendix E) emulsified 
in Montanide ISA-51 VG adjuvant. In a given patient, half of the vaccine solution will be 
administered subcutaneously and half intradermally, once each week (vaccines 1–3), then 
once every 3 weeks (vaccines 4–6), in rotating skin locations on extremities clinically 
uninvolved with melanoma. For each vaccine, a total of 2 mL of emulsion will be 
delivered, which will consist of 1 mL of Montanide ISA-51 VG and the MELITAC 12.1 
peptides. The vaccine dose will be divided and administered into 2 extremity sites 
uninvolved with melanoma (typically upper outer arm and/or upper lateral thigh). 
 
At each injection site, a single needle puncture is to be performed, with delivery of 
0.5 mL into the dermis and 0.5 mL into the subcutaneous tissue. This usually will require 
advancing the needle into the dermis, parallel with the skin surface, to deliver the first 
0.5 mL, then pulling the needle back to near the skin puncture site, and advancing it into 
the subcutaneous tissue for delivery of the remaining 0.5 mL. For the dermal injections, it 
is acceptable to make several passes of the needle as the emulsion is delivered, where 
those needle passes are oriented radially from the needle puncture site. 
 
8.4 
Montanide ISA-51 VG 
 
8.4.1 Product Description 
 
The adjuvant Montanide ISA-51 VG has been used in a number of clinical trials with 
little toxicity observed. The possible side effects of receiving Montanide VG adjuvant 
include anaphylaxis in response to one of the ingredients (rare). Such a reaction might 
include hives, rash, generalized swelling of the body, hypotension, dyspnea, and 
abdominal pain, and possibly death.  
 
 
8.4.2 How Supplied 
 
Montanide ISA-51 VG is supplied in a glass container as a sterile, clear, pale yellow 
liquid by Seppic, Inc. (Fairfield, NJ). It is commercially available from Seppic, Inc., and 
will be distributed by the University of Virginia. 
 
8.4.3 Solution Preparation 
 
The vaccine adjuvant Montanide ISA-51 VG is prepared as a GMP-grade agent, in 
single-use glass vials or ampules. Refer to Appendix E for complete vaccine preparation 
instructions. 
 
8.4.4 Storage Conditions 
 
Montanide ISA-51 VG should be stored at room temperature. 


NCI Protocol #: CITN-04 
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55 
 
8.4.5 Stability 
 
An expiration date for Montanide ISA-51 VG is provided by Seppic, Inc., and the drug 
should not be used beyond this date.  
 
8.4.6 Route of Administration 
 
Refer to Appendix E for complete vaccine preparation instructions. 
  
8.5 
Commerical Agent: N/A  
 
 
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
9.1 
Biomarker Studies 
 
9.1.1 Collection of Specimens 
 
9.1.1.1 Fine-Needle Aspiration (FNA) Biopsy of Tumor 
FNA biopsy will be prepared as detailed below and stored frozen in liquid nitrogen. 
9.1.1.2 Tumor Biopsies 
Biopsy specimens must include at least 100 mm3 of tumor tissue and ideally 1 cm3 or 
more.  The specimens may be obtained by excisional biopsy, incisional biopsy, or core 
biopsy.  Each surgical specimen or set of core biopsies will be divided into 5 portions:  
1/4th will be placed in RPMI and will be processed to yield cryopreserved viable cells for 
flow cytometric analysis, 1/4th will be fixed in formalin and then embedded in paraffin 
for histology, 1/6th will be flash frozen in OCT for histology, 1/6th will be flash frozen 
without medium for Kyn/Trp ratio and 1/6th will be flash frozen in RNA Later for gene 
expression.  (See Laboratory Manual for additional information).  
 
If an archived pre-treatment biopsy is obtained from a formalin-fixed paraffin-embedded 
(FFPE) tissue block, there must be at least 20 slides available for study. 
    
9.1.1.3 Blood  
Blood will be collected for serum and PBMC isolation as designated below. 
 
9.1.2 Processing and Shipping of Specimen(s) 
 
Tumor specimens will be collected as described above, at the bedside when tumor is 
biopsied. They will then be processed and shipped as specified below. 
 
9.1.2.1 Portion for single-cell suspensions 
This will be submitted to mechanical dissociation then, as appropriate, enzymatic 
digestion (typically collagenase, DNAase, and hyaluronidase). The resulting cells will be 
collected by centrifugation and cryopreserved viably in 10% dimethyl sulfoxide (DMSO) 
and either 12.5% HSA (Human serum albumin or 12.5% FCS (Fetal calf serum) using a 


NCI Protocol #: CITN-04 
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56 
 
controlled-rate freezer.  Samples will be stored at -80°C and then batch-shipped on dry 
ice to the CITN Central Laboratory. 
 
9.1.2.2 Portion for Formalin Fixation 
These will be placed in formalin, and shipped (ambient) overnight to the CITN Central 
Laboratory. After adequate fixation, samples will be embedded in paraffin and formalin-
fixed paraffin embedded (FFPE) blocks stored at room temperature. 
 
9.1.2.3 Portion for Quick-Freezing in OCT 
This will be placed in OCT at the patient bedside and placed immediately onto dry-ice for 
hardening. Samples will be stored at -80°C and then batch-shipped on dry ice to the 
CITN Central Laboratory. 
 
9.1.2.4 Portion for Quick-Freezing Without Media 
This will be placed in a cryovial and placed immediately into liquid nitrogen for flash 
freezing. Samples will be stored at -80°C or in liquid nitrogen and then batch-shipped on 
dry ice to the CITN Central Laboratory. 
 
9.1.2.5 Blood Samples  
A) Blood in red-top (or comparable) tubes for serum isolation and green-top tubes for 
plasma isolation, and CPT tubes (for RNA isolation) will be processed locally, 
aliquoted into cryovials, and frozen at -80°C. They will be batch-shipped on dry ice 
to the CITN Central Laboratory. 
 
B) Blood in green-top (or comparable) tubes for PBMC isolation and CellSave 
Preservation tubes will be shipped at ambient temperature in insulated containers to 
the CITN central laboratory at the University of Washington. 
 
9.1.3 Shipping of Specimens 
 
Fresh blood collected for PBMC isolation will be shipped at ambient temperature 
overnight in insulated containers to the CITN central laboratory. Biopsy specimens in 
formalin will be shipped with the green top tubes to the CITN Central Laboratory for 
paraffin embedding as described above.  (FFPE) tumor biopsies will be stored at room 
temperature, then shipped in batch periodically to the University of Virginia (Slingluff 
laboratory) for analysis. FNA biopsies will be stored in liquid nitrogen or at -80oC, then 
shipped in batch to the CITN Central Laboratory for later batch shipment to the laboratory 
of Drs. Marincola and Wang for analyses. Frozen serum, plasma and viably frozen tumor 
cells and frozen tumor tissue will be shipped in batch to the CITN Central Laboratory on 
dry ice for same day or overnight delivery.  
 
9.2 
Laboratory Correlative Studies 
 


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9.2.1 Immunohistochemical Evaluation of Tumor Biopsies - Laboratory Correlative Study 
#1 
Tumors will be assessed by IHC for pattern of T-cell distribution and infiltration of cells 
expressing a variety of antigens including CD3, CD4, CD8, CD56, CD34, CD45, CD20, 
CD138, CD163, DC-LAMP, FoxP3, PD-1, and IDO1, as well as PD-L1 on tumors. The 
primary endpoint of the trial will be a change in the number of CD8+ cells infiltrating 
tumor (per mm2) comparing pre- and post-treatment biopsies for each patient. We will 
use the assessment of total CD3+ T cells and total CD45+ lymphocytes as confirmatory 
assays. IHC staining will also be performed to detect other key parameters including 
IDO1 expression, and presence and patterns of CD4+ T cell and FoxP3+ Treg infiltration. 
These antibodies all work in FFPE tissue sections.  
 
Tissue sections will be processed with heat-induced antigen retrieval and stained as 
described [Erdag 2012], using antibodies to CD4, CD8, NKp46, CD31, CD45, CD20, 
CD3, CD138, CD163, DC-LAMP, FoxP3, PD-1, and IDO1. EnVision™ System 
(enzyme-conjugated polymer backbone coupled to secondary antibodies) and 3,30-
diaminobenzidine chromogen (Dako North America, Inc., Carpinteria, CA) will be 
applied to develop the staining. Positive controls for lymphocyte antibodies will include 
lymph node and for CD34 antibody, placenta. Negative control slides will use phosphate 
buffered saline instead of primary antibody, with other conditions held constant.  
 
If the tumor specimen is too small for evaluation of all antigens, the priority will be 
CD8 > CD3 > IDO > CD31 > CD45 > FoxP3 > remainder. Stained sections will be 
reviewed for type, density, and location of tumor-infiltrating immune cells, tumor cell 
type, necrosis, hemorrhage, and melanin pigment. At least 5 high-powered fields will be 
examined. Fields with no tumor tissue, more than 50% necrosis, or hemorrhage will be 
excluded. Stained cells will be enumerated by a single pathologist on each core in a high-
power microscope field, excluding cells within blood vessels or in hemorrhagic or 
necrotic areas. Cell counts will be normalized to per mm2. Alternatively, when automated 
image analysis software is available and validated, it may be used for quantification of 
the staining. Change in the number of tumor-infiltrating lymphocytes will be analyzed 
using standard descriptive statistical analyses described below.  
 
Immunotypes will be defined by staining for immune cells (CD45) and for intratumoral 
blood vessels (CD31) as described [Erdag 2012]. 
 
Additional histologic studies may be performed as appropriate to elucidate the 
immunologic changes in the tumor specimens. If IHC studies are needed using antibodies 
that do not work well in FFPE sections, or for immunofluorescence studies, one of the 
quick-frozen tissue samples will be used for those purposes. 
 
9.2.1.1 Site(s) Performing Correlative Study 
The primary endpoints (IHC for CD8 and CD3) will be evaluated on FFPE slides of 
tumor tissue at Phenopath Laboratories, Seattle, WA. All other IHC will be performed at 
the University of Virginia.  
 


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9.2.2 Gene Expression Analyses of Tumor Biopsies, Fine Needle Aspirates of Metastases, 
and Peripheral Blood—Laboratory Correlative Study #2 
 
Tumor biopsies will be obtained as described above for IHC analyses. FNA of melanoma 
metastases will be performed at each biopsy date, before the excisional/incisional/core 
biopsy; both tissues will be evaluated for gene signatures. Gene signatures will also be 
performed on PBMCs obtained before therapy and on days 21 and 42, the same day of 
the tumor biopsies. PBMC gene signatures may be compared to data of tumor biopsy, 
immunologic response, and clinical response.  
 
9.2.2.1 Collection of Specimen(s) 
For FNA a 22- or 23-gauge hypodermic needle will be inserted into the tumor and 
multiple passes with changing angles of insertion will be made through all quadrants of 
the tumor, while under suction. Tissue from the needle will be suspended in 10 mL of 
cold RPMI. For PBMC, a CPT tube will be drawn and processed as described below. 
 
9.2.2.2 Handling of Specimen(s) 
Specimens will be collected at the clinical sites as described above and centrifuged at 
1500 rpm for 5 minutes at 4°C. The cell pellet will then be harvested, red blood cells 
lysed as per the technique described by Weiss et al [Weiss 2011]. Cells will be isolated 
by centrifugation and resuspended in Qiazol to obtain total RNA. Samples will be stored 
at -80°C and then batch-shipped as described below. 
 
9.2.2.3 Shipping of Specimen(s) 
All RNA samples will be batched and shipped on dry ice using FedEx® overnight 
delivery to the CITN Central Laboratory. The CITN Central Laboratory will hold 
specimens for shipment to the laboratory of Dr. Marincola and Wang for gene expression 
array studies. Any leftover sample will be returned to the CITN Central Laboratory for 
storage and future ancillary studies. 
 
9.2.2.4 Site(s) Performing Correlative Study 
Gene expression studies, including analyses of the data, will be conducted in the 
laboratory of Dr. Francesco Marincola, Chief Research Officer of Sidra Medical and 
Research Center, Qatar.  
 
9.2.3 CD8+ T-cell IFN-gamma Responses to the 12-peptide Mixture, and CD4+ T-cell 
Responses to Tetanus Peptide—Laboratory Correlative Study #3 
 
PBMC (and lymphocytes isolated from tumor biopsies, when available) will be analyzed 
by IFN-gamma ELISpot assay for responses to the 12-peptide mixture. Assessment of 
immunologic response will be based on a fold-increase measure from baseline as well as 
using a positivity threshold. Since 11 of the 12 melanoma-associated immunizing 
peptides are 9- and 10-mers, it is safely presumed that IFN-gamma ELISpot responses 
among PBMC will derive from CD8+ T cells. No depletion of CD4+ T cells is planned for 
the ELISpot testing. The frequency of CD8+ T cells specific to 8 of the 12 immunizing 
peptides will be confirmed using tetramers and flow cytometric analysis. CD8+ T cell 


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59 
 
responses will be assayed directly ex vivo (using viably cryopreserved specimens), after 
stimulation with the 12-peptide mixture (10 μg/mL each) at baseline (i.e., before 
initiating INCB024360 treatment), at week 3 (before the first immunization with 
MELITAC12.1), at weeks 6, and optionally at week 16 (2 weeks after the last dose of 
MELITAC12.1).  
 
Similarly, these assays will include the tetanus peptide and multiple controls (CEF 
peptide, negative controls, etc.). Responses to the tetanus peptide will be interpreted as 
helper (CD4+) T-cell responses.  
 
9.2.3.1 Collection of Specimen(s) 
Whole blood will be collected into heparinized (green top) tubes.  
 
9.2.3.2 Handling of Specimen(s)  
Samples will be collected at room temperature and shipped to the CITN Central 
Laboratory the same day as the blood draw, so that the sample is received at the central 
laboratory within 24 hours of blood draw. PBMC will be isolated and cryopreserved 
before testing. 
 
9.2.3.3 Shipping of Specimen(s)  
Samples will be shipped at ambient temperature for overnight FedEx delivery. Clinical 
research sites will utilize a web-based specimen tracking system (BSI-II) to communicate 
with the CITN central laboratory. 
 
9.2.3.4 Site(s) Performing Correlative Study  
The IFN-gamma ELISpot assay will be conducted at the CITN Central Laboratory at the 
University of Washington Immunologic Monitoring Laboratory in Seattle, in 
collaboration with the laboratory of Dr. Slingluff at the University of Virginia. Flow 
cytometry for tetramer-positive cells will be conducted in the laboratory of Dr. Slingluff. 
 
9.2.4 Quantification of PBMC and T-cell Subsets—Laboratory Correlative Study #4 
 
The effect of treatment on T lymphocyte number and phenotype (i.e., CD8+, effector 
memory CD8+, central memory CD8+, CD4+, CD4+ Treg, naïve subsets) will be 
assessed. The frequency and percentage of PBMC subsets will be determined using 
multiparameter flow cytometric analysis of whole blood. The markers include CD3, CD8, 
CD4, CD39, CD56, Foxp3, CD127, CD45RA, CD45RO, CCR7, CD28, CD27, CD25, 
CD122, CD86, CD14, CD16, CD19, CD123, and CD11c. Changes in myeloid-derived 
suppressor cell populations will also be assessed by flow cytometry.  
 
The effect of INCB024360 and MELITAC 12.1 on lymphocyte number and phenotype 
will be assessed at baseline (i.e., before initiating INCB024360 treatment), week 3 
(before first immunization with MELITAC12.1), week 6 (before the second set of 
MELITAC12.1 vaccines), week 14 (just before the last dose of MELITAC12.1), and, if 
possible, week 16 (2 weeks after the last dose of MELITAC12.1).  
 


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60 
 
9.2.4.1 Collection of Specimen(s)  
Whole blood will be collected into heparinized tubes. 
 
9.2.4.2 Handling of Specimen(s)  
Samples will be collected at room temperature and shipped to the CITN Central 
Laboratory the same day as the blood draw, so that the sample is received at the central 
laboratory within 24 hours of blood draw.  
 
9.2.4.3 Shipping of Specimen(s)  
Samples will be shipped at ambient temperature for overnight FedEx delivery. Clinical 
research sites will utilize a web-based specimen tracking system (BSI-II) to communicate 
with the CITN central laboratory. 
 
9.2.4.4 Sites Performing Correlative Study 
The immunophenotyping assays will be conducted at the CITN Central Laboratory.  
 
9.2.5 Intratumor and Whole Blood Kyn/Trp Ratios—Laboratory Correlative Study #5 
 
Kyn/Trp ratios will be assayed in patients receiving a regimen of INCB024360 plus 
MELITAC 12.1 vaccine as measured in peripheral blood and in intra-tumoral specimens 
at baseline and on specimens obtained at subsequent tumor biopsy timepoints. 
 
Evaluations will occur at baseline (week 0) and after each vaccination. 
 
9.2.5.1 Collection of Specimens 
Whole blood will be collected into heparinized tubes. 
 
Biopsy specimens will be collected as described in Section 9.1.1 
 
9.2.5.2 Handling of Specimen(s)  
Blood samples will be processed locally, and frozen aliquots shipped to the CITN Central 
Laboratory. The Central Laboratory will distribute aliquots to Incyte where testing will 
be done in a blinded fashion.  
 
Biopsy specimens will be collected and stored at -80°C (if frozen) at the collection site. 
 
9.2.5.3 Shipping of Specimens 
Frozen plasma and flash frozen biopsy specimens will be batch shipped to the CITN 
Central Laboratory. The CITN Central Laboratory will ship specimens to Incyte 
Corporation by FedEx overnight delivery.  
 
9.2.5.4 Site(s) Performing Correlative Study  
The Kyn/Trp analysis will be conducted at Incyte Corporation. 
 


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61 
 
9.2.6 Other Immunologic Assessments—Laboratory Correlative Study #6 
 
9.2.6.1 Collection of Specimens  
At baseline, week 3, week 6 and optionally at week 16, 10 mL of serum will be collected 
in red-top tubes for serum storage, and 10 mL will be collected in green-top tubes for 
plasma storage.  
 
9.2.6.2 Handling of Specimen(s)  
Samples will be collected at room temperature. Blood for serum, plasma, and the cell 
pellet into RNA will be processed at the Local Lab within 4 hours at the collection site, 
aliquoted according to protocol, and frozen at -80°C.  
 
9.2.6.3 Shipping of Specimen(s)  
Serum, plasma and cell pellet into RNA will be processed at each clinical site and batch-
shipped on dry ice overnight to the CITN central laboratory. Clinical research sites will 
utilize a web-based specimen tracking system (BSI-II) to communicate with the CITN 
central laboratory. Frozen samples will be batch-shipped to the CITN central 
laboratory/repository on dry ice.  
 
9.2.6.4 Site(s) Performing Correlative Study  
It is anticipated that a number of CITN investigators with laboratories may propose 
ancillary studies to be conducted on CITN repository specimens, but the specific sites 
have yet to be determined. 
 
9.3 
Special Studies: Cytokine and INCB024360 Blood Levels 
 
9.3.1 Collection of Specimens  
10 mL of serum will be collected in red-top tubes for determining the INCB024360 level, 
and cytokine levels.  
 
9.3.2 Handling of Specimen(s)  
Samples will be collected at room temperature and processed in the local laboratory 
within 4 hours of blood draw, aliquoted according to protocol, and frozen at -80°C.  
 
9.3.3 Shipping of Specimen(s)  
Frozen aliquots of serum and plasma will be batch-shipped to the CITN Central 
Laboratory. The Central Laboratory will distribute aliquots to Incyte.  Clinical research 
sites will utilize a web-based specimen tracking system (BSI-II) to communicate with the 
CITN Central Laboratory.  
 
9.3.4 Site(s) Performing Correlative Study  
The INCB024360 drug levels will be conducted at Incyte Corporation. 


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62 
 
10. STUDY CALENDAR 
All baseline evaluations are to be conducted within 1 week before start of protocol therapy. Scans and x-rays must be done ≤4 weeks before the start of therapy. In 
the event that the patient’s condition is deteriorating, laboratory evaluations should be repeated within 48 hours before initiating the next cycle of therapy. 
 
Pre- 
Study 
-30 day 
Pre- 
Study 
-7 day 
Wk 0 
Day 0 
Wk 1 
Day 7 
+/- 2 d 
Wk 2 
Day 14 
+/- 2d 
Wk 3 
Day 21 
+/- 2d 
Wk 4 
Day 28
+/- 2d
Wk 5 
Day 35 
+/- 2d 
Wk 6 
Day 42 
+/- 2d 
Wk 8 
Day 56 
+/- 2d 
Wk 11 
Day 77 
+/- 2d 
Wk 14 
Day 98 
+/-2d 
Wk 16 
Day 112 
+/-2d 
Repeat b 
Cycles 
Wks c 
+/-2d 
10 Wk 
Post-Tx 
F/U‡ 
F/U 
+/-14d 
36 Wk  
Post-
Tx FU 
F/U 
+/-30d 
Off 
Study 
INCB024360 daily 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
 
 
MELITAC 12.1 
vaccine** 
 
 
 
 
 
X 
X 
X 
 
X 
X 
X 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Concomitant 
medication 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Physical exam 
 
X 
X 
 
 
X 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
Vital signs 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Height 
 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
Weight 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Performance status 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Tumor Biopsy1,2 * 
 
 
Xa 
 
 
X 
 
 
X3 
 
 
 
X3 
 
 
 
X1 
FNA4,5 
 
 
Xa 
 
 
X 
 
 
X 
 
 
 
X3 
 
 
 
X1 
CBC w/diff, plts (local 
lab) 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Serum chemistry6 
(local lab) 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
B-HCG 7  (local lab) 
 
 
X7 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PBMC5 and T-cell 
subsets 
 
 
X 
 
 
X 
 
 
X 
 
 
X 
X8 
 
 
 
 
IFN-gamma 
ELISpot*** 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
X 
 
 
 
Confirmatory Tetramer 
staining 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
 
 
 
 


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63 
 
 
Pre- 
Study 
-30 day 
Pre- 
Study 
-7 day 
Wk 0 
Day 0 
Wk 1 
Day 7 
+/- 2 d 
Wk 2 
Day 14 
+/- 2d 
Wk 3 
Day 21 
+/- 2d 
Wk 4 
Day 28
+/- 2d
Wk 5 
Day 35 
+/- 2d 
Wk 6 
Day 42 
+/- 2d 
Wk 8 
Day 56 
+/- 2d 
Wk 11 
Day 77 
+/- 2d 
Wk 14 
Day 98 
+/-2d 
Wk 16 
Day 112 
+/-2d 
Repeat b 
Cycles 
Wks c 
+/-2d 
10 Wk 
Post-Tx 
F/U‡ 
F/U 
+/-14d 
36 Wk  
Post-
Tx FU 
F/U 
+/-30d 
Off 
Study 
Kyn/Trp ratio 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X* 
 
 
 
 
RNA Cell Pellet for 
gene expression 
analysis 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
 
 
 
 
Serum Cytokines 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
 
 
 
 
INCB024360 level 
 
 
 
 
 
X 
 
 
X 
 
 
 
X 
 
 
 
 
Circulating tumor cells  
 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
PBMC storage*** 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X8 
X 
 
 
 
Serum storage 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X8 
 
 
 
 
EKG (pre-study and as 
indicated) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse event 
evaluation 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
Tumor measurements  
X 
 
 
Tumor measurements are repeated every 12 weeks or per institutional standard of care. Documentation (radiologic) must be 
provided for patients removed from study for progressive disease. 
Radiologic evaluation9 X 
 
. 
 
 
 
 
 
 
X9 
 
 
X9 
 
X9 
 
 
aTumor biopsy and FNA may be obtained up to 14 days prior to starting therapy.  For patients with only one or two tumors approachable for biopsy, available tumor blocks from 
prior biopsies can serve as the pretreatment sample provided at least 20 unstained slides are available.   
b Patients who are eligible to receive additional cycles of IDO inhibitor without vaccinations will maintain the same visit schedule as cycle 1 
NOTE: If additional cycles of IDO inhibitor are given only the end of treatment biopsy is to be obtained when possible. 
Note: If additional cycles of IDO inhibitor are given a reduced volume of blood will be drawn for correlative assays. See footnote *** below for details. 
c A delay of up to 60 days between treatment cycles will be allowed. 
1Tumor biopsies will be assessed by immunohistochemistry (IHC) 
2If optional biopsy performed 
3Optional biopsy 
4FNA (Fine Needle Aspirate): before the excisional/incisional/core biopsy  
5Gene Expression Analyses of tumor biopsies, FNA, and PBMC 
6Serum chemistries include: albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, phosphorus, potassium, total protein, SGOT 
[AST], SGPT [ALT], sodium. 
7Serum Pregnancy test done 48 hours before start of therapy 
8Optional blood draw 
9CT, MRI, or PET within 0 days (14 days preferred) is acceptable for imaging assessment purposes 


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64 
 
9 Radiologic evaluations done at weeks 8 and 16 +/-7 days. If a clinical response is seen at week 8 a confirmatory scan is to be repeated at least 4 weeks later (week 12), therefore 
the week 16 scan can be delayed an additional 4 weeks and repeated at week 20. After week 26 scans are to be done every 12 weeks in patients without progression through year 5 
of follow-up. 
* Pretreatment biopsies should be performed before the first treatment with IDO inhibitor, within 14 days of that start date. 
**A participant will be taken off protocol treatment if >1 vaccination is delayed [ 3 to 7 days] during the treatment period. 
***For cycles beyond cycle 1, correlative science blood draws will be limited to only IFN-gamma ELISpot/PBMC Storage. 
 
 


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65 
 
11. 
MEASUREMENT OF EFFECT 
 
In all patients, assessments for toxicology, response, and pharmacodynamics for immunologic 
effect will be performed. Effects of IDO inhibition on systemic vaccine-induced immunity will be 
assessed by evaluating peripheral blood immune responses to the MELITAC 12.1 vaccine. The 
comparator for immune responses will be published experience with similar patients treated with 
the same vaccine regimen but without INCB024360 [Slingluff, 2011; Slingluff 2009]. If 
substantial changes at sites of tumor are detected in response to INCB024360 alone or in 
combination with vaccine, subsequent iterative trials will determine the individual contributions of 
INCB024360 and the vaccine. From these data, we will endeavor to associate any observed 
changes with the expression of IDO1 protein by IHC in tumor or tumor-infiltrating cells. 
 
The primary endpoint will be changes in the concentration and number of CD8+ cells infiltrating 
tumor before and after treatment with each patient serving as their own control. We will use the 
assessment of total CD3 T cells and total CD45 lymphocytes as confirmatory assays. The 
histologic pattern of T-cell infiltration and changes in pattern will be concurrently assessed and 
chronicled. Whether to expect a small or large effect on the tumor microenvironment from the 
therapy remains unknown, thus the endpoint objectives are exploratory and the trial is sized 
accordingly. A prior study of changes in the tumor microenvironment with systemic immune 
therapy (IL-2) identified significant changes in the tumor microenvironment with a sample size of 
13 patients. The sample size of 12 patients is a reasonable number for this initial study to 
determine whether INCB024360 plus vaccine has an appreciable effect on the tumor 
microenvironment. 
 
Each patient’s tumor(s) will be biopsied before therapy and during therapy to assess the extent to 
which INCB024360 plus MELITAC 12.1 alters the tumor as evaluated by IHC and transcriptome 
analysis. In addition, the effect on immune responses in peripheral blood and on PBMC phenotype 
and character will be assessed (1) before therapy, (2) on day 21, before the first vaccine, (3) on day 
42, a week after the third vaccine and coinciding with the day 42 biopsy, and (4) at week 16, 
2 weeks after the sixth vaccine.  
 
Therapeutic response will be assessed by serial scans and measures of circulating tumor cells. 
Overall clinical response rate and tumor progression will be assessed by evaluating nonbiopsied 
lesions if present, using standard methods (RECIST and irRC), including physical exam and CT 
scans performed before therapy, at weeks 8, 16, 26 and every 3 months through 1 year according 
to standard practice.  If a clinical response is seen at week 8 a confirmatory scan is to be repeated 
at least 4 weeks later (week 12), therefore obtaining the week 16 scan may be delayed an 
additional 4 weeks and repeated at week 20. After week 26 scans are to be done every 12 weeks in 
patients without progression. Both systems will be used for reporting response. Patients may be 
managed in accordance with irRC guidelines as published by Wolchok [Wolchok 2009]. The irRC 
criteria allow for reporting as “response” patients that respond after a period of progression. The 
irRC criteria accordingly do not demand immediate cessation of experimental therapy with the first 
sign of progression. 
 
In addition, the safety and tolerability of INCB024360 with MELITAC 12.1 will be assessed in 
this study utilizing the National Cancer Institute Common Terminology Criteria for Adverse 
Events v4.0 (NCI CTCAE v4.0).  


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66 
11.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, patients should be evaluated for response according to 
standard practice at weeks 8, 16, 26 and every 3 months thereafter through year 1 according 
to standard practice. In addition to a baseline scan, confirmatory scans should also be 
obtained at least 4 weeks after the initial documentation of objective response (i.e., week 
12). A 4 week delay in obtaining the week 16 scans, (i.e., obtaining scans at week 20), 
would be acceptable due to the timing of obtaining confirmatory response scans. 
. 
Response and progression will be evaluated in this study using the new international 
criteria proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) 
guideline (version 1.1) [Eisenhauer 2009]. Changes in the largest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant 
lymph nodes are used in the RECIST criteria. Results will be reported by RECIST and 
irRC guidelines.  
 
11.1.1 Definitions 
 
Evaluable for toxicity. All patients will be evaluable for toxicity from the time of their first 
treatment with INCB024360 followed by MELITAC 12.1 vaccine.  
 
Evaluable for objective response. Only those patients who have measurable disease present 
at baseline, have received at least one cycle of therapy, and have had their disease re-
evaluated will be considered evaluable for response. These patients will have their response 
classified according to the definitions stated below. (NOTE: Patients who exhibit objective 
disease progression before the end of cycle 1 will also be considered evaluable.) 
 
Evaluable Non-target Disease Response. Patients who have lesions present at baseline that 
are evaluable but do not meet the definitions of measurable disease, have received at least 
one cycle of therapy, and have had their disease re-evaluated will be considered evaluable 
for non-target disease. The response assessment is based on the presence, absence, or 
unequivocal progression of the lesions.  
 
11.1.2 Disease Parameters 
 
Measurable disease. Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter to be recorded) as ≥20 mm by chest 
x-ray or as ≥10 mm with CT scan, MRI, or calipers by clinical exam. All tumor 
measurements must be recorded in millimeters (or decimal fractions of centimeters). 
 
NOTE: Tumor lesions that are situated in a previously irradiated area might or might not 
be considered measurable 
 
Malignant lymph nodes. To be considered pathologically enlarged and measurable, a 
lymph node must be ≥15 mm in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm). At baseline and in follow-up, only the 
short axis will be measured and followed. 


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67 
Non-measurable disease. All other lesions (or sites of disease), including small lesions 
(longest diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), 
are considered non-measurable disease. Bone lesions, leptomeningeal disease, ascites, 
pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
and abdominal masses (not followed by CT or MRI), are considered as non-measurable. 
 
NOTE: Cystic lesions that meet the criteria for radiographically defined simple cysts 
should not be considered as malignant lesions (neither measurable nor nonmeasurable) 
since they are, by definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable 
lesions, if they meet the definition of measurability described above. However, if non-
cystic lesions are present in the same patient, these are preferred for selection as target 
lesions. 
 
Target lesions. All measurable lesions up to a maximum of 2 lesions per organ and 
5 lesions in total, representative of all involved organs, should be identified as target 
lesions and recorded and measured at baseline. Target lesions should be selected on the 
basis of their size (lesions with the longest diameter), be representative of all involved 
organs, but in addition should be those that lend themselves to reproducible repeated 
measurements. It may be the case that, on occasion, the largest lesion does not lend itself to 
reproducible measurement in which circumstance the next largest lesion which can be 
measured reproducibly should be selected. A sum of the diameters (longest for non-nodal 
lesions, short axis for nodal lesions) for all target lesions will be calculated and reported as 
the baseline sum diameters. If lymph nodes are to be included in the sum, then only the 
short axis is added into the sum. The baseline sum diameters will be used as reference to 
further characterize any objective tumor regression in the measurable dimension of the 
disease. 
 
Non-target lesions. All other lesions (or sites of disease) including any measurable lesions 
over and above the 5 target lesions should be identified as non-target lesions and should 
also be recorded at baseline. Measurements of these lesions are not required, but the 
presence, absence, or in rare cases unequivocal progression of each should be noted 
throughout follow-up.  
 
11.1.3 Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or calipers. 
All baseline evaluations should be performed as closely as possible to the beginning of 
treatment and never more than 4 weeks before the beginning of the treatment. 
 
The same method of assessment and the same technique should be used to characterize 
each identified and reported lesion at baseline and during follow-up. Imaging-based 
evaluation is preferred to evaluation by clinical examination unless the lesion(s) being 
followed cannot be imaged but are assessable by clinical exam. 
 
Clinical lesions Clinical lesions will only be considered measurable when they are 


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superficial (e.g., skin nodules and palpable lymph nodes) and ≥10 mm diameter as assessed 
using calipers (e.g., skin nodules). In the case of skin lesions, documentation by color 
photography, including a ruler to estimate the size of the lesion, is recommended.  
 
Chest x-ray Lesions on chest x-ray are acceptable as measurable lesions when they are 
clearly defined and surrounded by aerated lung. However, CT is preferable.  
 
Conventional CT and MRI This guideline has defined measurability of lesions on CT scan 
based on the assumption that CT slice thickness is 5 mm or less. If CT scans have slice 
thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the 
slice thickness. MRI is also acceptable in certain situations (e.g., for body scans).  
 
Use of MRI remains a complex issue. MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which 
greatly impact image quality, lesion conspicuity, and measurement. Furthermore, the 
availability of MRI is variable globally. As with CT, if an MRI is performed, the technical 
specifications of the scanning sequences used should be optimized for the evaluation of the 
type and site of disease. Furthermore, as with CT, the modality used at follow-up should be 
the same as was used at baseline and the lesions should be measured/assessed on the same 
pulse sequence. It is beyond the scope of the RECIST guidelines to prescribe specific MRI 
pulse sequence parameters for all scanners, body parts, and diseases. Ideally, the same type 
of scanner should be used and the image acquisition protocol should be followed as closely 
as possible to prior scans. Body scans should be performed with breath-hold scanning 
techniques, if possible. 
 
PET-CT At present, the low dose or attenuation correction CT portion of a combined PET-
CT is not always of optimal diagnostic CT quality for use with RECIST measurements. 
However, if the site can document that the CT performed as part of a PET-CT is of 
identical diagnostic quality to a diagnostic CT (with IV and oral contrast), then the CT 
portion of the PET-CT can be used for RECIST measurements and can be used 
interchangeably with conventional CT in accurately measuring cancer lesions over time. 
Note, however, that the PET portion of the CT introduces additional data which may bias 
an investigator if it is not routinely or serially performed.  
 
Ultrasound Ultrasound is not useful in assessment of lesion size and should not be used as a 
method of measurement. Ultrasound examinations cannot be reproduced in their entirety 
for independent review at a later date and, because they are operator dependent, it cannot 
be guaranteed that the same technique and measurements will be taken from one 
assessment to the next. If new lesions are identified by ultrasound in the course of the 
study, confirmation by CT or MRI is advised. If there is concern about radiation exposure 
at CT, MRI may be used instead of CT in selected instances. 
 
Endoscopy, Laparoscopy The utilization of these techniques for objective tumor evaluation 
is not advised. However, such techniques may be useful to confirm complete pathological 
response when biopsies are obtained or to determine relapse in trials where recurrence 
following complete response (CR) or surgical resection is an endpoint. 
 


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Tumor markers Tumor markers alone cannot be used to assess response. If markers are 
initially above the upper normal limit, they must normalize for a patient to be considered in 
complete clinical response. Specific guidelines for both CA-125 response (in recurrent 
ovarian cancer) and PSA response (in recurrent prostate cancer) have been published 
[Bubley 1999; Rustin 2004; Scher 2008]. In addition, the Gynecologic Cancer Intergroup 
has developed CA-125 progression criteria which are to be integrated with objective tumor 
assessment for use in first-line trials in ovarian cancer [Vergote 2000]. 
 
Cytology, Histology These techniques can be used to differentiate between partial 
responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor 
types, such as germ cell tumors, where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or 
worsens during treatment when the measurable tumor has met criteria for response or stable 
disease is mandatory to differentiate between response or stable disease (an effusion may 
be a side effect of the treatment) and progressive disease. 
 
FDG-PET While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible ‘new’ disease). New lesions on the basis of 
FDG-PET imaging can be identified according to the following algorithm:  
a. Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD 
based on a new lesion. 
b. No FDG-PET at baseline and a positive FDG-PET at follow-up: If the positive FDG-
PET at follow-up corresponds to a new site of disease confirmed by CT, this is PD. If 
the positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, 
additional follow-up CT scans are needed to determine if there is truly progression 
occurring at that site (if so, the date of PD will be the date of the initial abnormal FDG-
PET scan). If the positive FDG-PET at follow-up corresponds to a pre-existing site of 
disease on CT that is not progressing on the basis of the anatomic images, this is not 
PD. 
c. FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy 
in cases where a residual radiographic abnormality is thought to represent fibrosis or 
scarring. The use of FDG-PET in this circumstance should be prospectively described 
in the protocol and supported by disease-specific medical literature for the indication. 
However, it must be acknowledged that both approaches may lead to false positive CR 
due to limitations of FDG-PET and biopsy resolution/sensitivity. 
 
NOTE: A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake 
greater than twice that of the surrounding tissue on the attenuation corrected image. 
 
11.1.4 Response Criteria  
 
11.1.4.1 
Evaluation of Target Lesions by RECIST 
 
Complete Response (CR): Disappearance of all target lesions. Any pathological lymph 
nodes (whether target or no-ntarget) must have reduction in short axis to <10 mm. 


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Partial Response (PR): At least a 30% decrease in the sum of the diameters of target 
lesions, taking as reference the baseline sum diameters. 
 
Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target 
lesions, taking as reference the smallest sum on study (this includes the baseline sum if 
that is the smallest on study). In addition to the relative increase of 20%, the sum must 
also demonstrate an absolute increase of at least 5 mm. (NOTE: the appearance of one 
or more new lesions is also considered progressions). 
 
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum diameters while on 
study. 
 
11.1.4.2 
Evaluation of Non-target Lesions by RECIST 
 
Complete Response (CR): Disappearance of all non-target lesions and normalization of 
tumor marker level. All lymph nodes must be non-pathological in size (<10 mm short 
axis). 
 
NOTE: If tumor markers are initially above the upper normal limit, they must 
normalize for a patient to be considered in complete clinical response. 
 
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance 
of tumor marker level above the normal limits. 
 
Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions. Unequivocal progression should not 
normally trump target lesion status. It must be representative of overall disease status 
change, not a single lesion increase.  
 
Although a clear progression of “non-target” lesions only is exceptional, the opinion of 
the treating physician should prevail in such circumstances, and the progression status 
should be confirmed at a later time by the review panel (or Principal Investigator). 
 
11.1.4.3 
Evaluation of Target Lesions by irRC  
 
Complete Response (irCR): Complete disappearance of all lesions (whether measurable 
or not, and no new lesions) confirmation by a repeat, consecutive assessment no less 
than 4 weeks from the date first documented.  
 
Partial Response (irPR): A ≥50% decrease in tumor burden compared with baseline in 
2 observations at least 4 weeks apart. (NOTE: For irRC, index and measurable lesions 
are taken into account. At the baseline tumor assessment, the sum of the products of the 
2 largest perpendicular diameters (SPD) of all index lesions (5 lesions per organ, up to 
10 visceral lesions and 5 cutaneous index lesions) is calculated. At each subsequent 
tumor assessment, the SPD of the index lesions and of the new, measurable lesions (≥5 
× 5mm; up to 5 new lesions per organ: 5 new cutaneous lesions and 10 visceral lesions) 


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are added together to provide the total tumor burden:  
 
Tumor Burden = SPDindex lesions + SPDnew, measurable lesions 
 
Progressive Disease (irPD): At least 25% increase in tumor burden compared with 
nadir (at any single time point) in 2 consecutive observations at least 4 weeks apart. 
(NOTE: The appearance of 1 or more new lesions does not define progression but does 
preclude irCR). 
 
Stable Disease (irSD): A 50% decrease in tumor burden compared with baseline cannot 
be established, nor can a 25% increase compared with nadir. 
 
11.1.4.4 
Evaluation of Best Overall Response (RECIST)  
 
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started). The patient’s best 
response assignment will depend on the achievement of both measurement and 
confirmation criteria. 
 
For Patients with Measurable Disease (i.e., Target Disease) 
Target 
Lesions 
Nontarget 
Lesions 
New Lesions
Overall 
Response
Best Overall Response when 
Confirmation is Required*
CR 
CR 
No
CR
≥4 wks. Confirmation**
CR 
Non-CR/Non-PD No
PR
≥4 wks. Confirmation** 
CR 
Not evaluated 
No
PR
PR 
Non-CR/Non-
PD/not evaluated 
No
PR
SD 
Non-CR/Non-
PD/not evaluated 
No
SD
Documented at least once ≥4 wks. 
from baseline** 
PD 
Any 
Yes or No
PD
no prior SD, PR or CR 
Any 
PD*** 
Yes or No
PD
Any 
Any 
Yes
PD
* See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. 
** Only for nonrandomized trials with response as primary endpoint. 
*** In exceptional circumstances, unequivocal progression in nontarget lesions may be accepted as 
disease progression. 
 
NOTE: Patients with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be reported as 
“symptomatic deterioration.” Every effort should be made to document the objective 
progression even after discontinuation of treatment.
 
For Patients with Non-measurable Disease (i.e., Non-target Disease) 
Nontarget Lesions 
New Lesions
Overall Response 
CR 
No
CR
Non-CR/non-PD 
No
Non-CR/non-PD* 
Not all evaluated 
No
not evaluated 


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Unequivocal PD 
Yes or No
PD
Any 
Yes
PD
 
“Non-CR/non-PD” is preferred over “stable disease” for nontarget disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials so to assign this 
category when no lesions can be measured is not advised
 
11.1.5 Duration of Response 
 
Duration of overall response: The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date 
that recurrent or progressive disease is objectively documented (taking as reference for 
progressive disease the smallest measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first met for 
CR until the first date that progressive disease is objectively documented. 
 
Duration of stable disease: Stable disease is measured from the start of the treatment until 
the criteria for progression are met, taking as reference the smallest measurements recorded 
since the treatment started, including the baseline measurements.  
 
11.1.6 Progression-Free Survival – N/A 
 
11.1.7 Response Review 
 
No review of response rate is contemplated. Investigator determined responses will be 
chronicled. 
 
11.2 
Antitumor Effect – Hematologic Tumors - N/A 
 
11.3 
Other Response Parameters 
 
11.3.1 Circulating Tumor Cells 
 
Circulating tumor cells will be enumerated by the approved CELLSEARCH® assay 
(Veridex LLC, Raritan, NJ) as exploratory analysis. 
 
 
12. DATA REPORTING/REGULATORY REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements). 
 


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12.1  Data Reporting 
 
12.1.1 Method 
 
This study will be monitored by the Clinical Data Update System (CDUS) Version 3.0. 
Cumulative protocol- and patient-specific CDUS data will be submitted electronically to 
CTEP on a quarterly basis, either by FTP burst of data or via the CDS web application. 
Reports are due January 31, April 30, July 31, and October 31. Instructions for submitting 
data using the CDUS can be found on the CTEP Web site: 
(http://ctep.cancer.gov/reporting/cdus.html)  
 
Note: This study has been assigned to CDUS-Abbreviated reporting. No adverse event 
reporting (routine or expedited) is required to be reported via CDUS. 
 
12.1.2 Responsibility for Data Submission 
 
The CITN COSC is responsible for compiling and submitting CDUS data for all 
participants. The Coordinating Center will submit the data quarterly. The date for 
submission to the CITN will be set by them. When setting the dates, allow time for 
Coordinating Center compilation, Principal Investigator review, and timely submission to 
CTEP by the quarterly deadlines (see Section 12.1.1).  
 
The CITN COSC is responsible for compiling and submitting CDUS data to CTEP for all 
participants and for providing the data to the Principal Investigator for review.  
12.2 
CTEP Multicenter Guidelines 
 
This protocol will adhere to the policies and requirements of the CTEP Multicenter 
Guidelines. The specific responsibilities of the Principal Investigator and the Coordinating 
Center (Study Coordinator) and the procedures for auditing are presented in Appendix B. 
 
 The CITN COSC is responsible for distributing all IND Action Letters or Safety 
Reports received from CTEP to all participating institutions for submission to their 
individual IRBs for action as required. 
 
 Agent will be supplied by Incyte Corporation. Agent distribution to a participating 
site will occur only after all required regulatory documents have been submitted to 
the appropriate institution at the direction of the CITN Coordinating Center. 
 
12.3 
Collaborative Agreements Language – N/A 
 
 


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13. STATISTICAL CONSIDERATIONS 
 
13.1 
Study Design/Endpoints 
 
The proposed study is a Phase II, open label, multicenter study of the administration of 
INCB024360, an IDO1 inhibitor, plus a multipeptide melanoma vaccine, MELITAC 12.1, 
in patients with advanced (i.e., surgically incurable stage III or IV) melanoma having tissue 
amenable to serial biopsy. 
 
The first 3 patients will be administered the INCB024360 in a reduced amount of 300 mg 
bid and enrolled in a staggered design with a 2-week waiting period between each of the 
first 3 patients (Table 5.1). This is a safety precaution due to unknown effects of the 
combination of INCB024360 with the multipeptide melanoma vaccine. Although both 
agents have excellent safety profiles, unexpected toxicities could occur when used together. 
 
Each patient’s tumor(s) will be biopsied before therapy and during therapy to assess the 
effects of INCB024360 and vaccine by IHC and transcriptome analysis (Table 5.1). 
 
INCB024360 is expected to normalize serum Kyn/Trp ratios, in turn altering the tumor 
microenvironment, which includes the number and character of tumor-infiltrating T cells. 
The addition of MELITAC 12.1, a multipeptide melanoma vaccine, will be used to 
compare INCB024360 alone and with the vaccine. Effects of IDO inhibition on systemic 
vaccine-induced immunity will be assessed by evaluating peripheral blood immune 
responses to the MELITAC 12.1 vaccine. The comparator for immune responses will be 
taken from published experience with similar patients treated with the same vaccine 
regimen but without INCB024360 [Slingluff 2011; Slingluff 2009]. 
 
13.2 
Primary Endpoint 
 
Published data on immune cell infiltration of melanoma metastases showed that amongst 
148 metastases, CD8 T cells ranged from 0 to 592 per mm2. The mean was 137, with 
standard deviation of 143; median 94 per mm2.[ Erdag, Cancer Research 2012] 
   
The primary endpoint will be changes in the concentration and number of CD8+ cells 
infiltrating tumor pre- and post-treatment with each patient serving as their own control so 
that relative increases within each patient will be assessed. We will use the assessment of 
total CD3 T cells and total CD45 lymphocytes as confirmatory assays. Twelve patients 
should enable adequate power to discern large changes (e.g. increases of about 1 SD of the 
original data set.) 
 
13.3 
Sample Size/Accrual Rate 
 
The study plans to enroll a total of 12 patients at 3 or 4 clinical research sites. Each patient 
will act as their own control. Patients without adequate sampling for immune responses 
will be replaced. 
Accrual rate of patients is expected to be approximately 3 patients per month. 
 


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13.4 
Stratification Factors - None 
 
13.5 
Analysis of Secondary Endpoints  
 
13.5.1 To determine whether a regimen of INCB024360 that normalizes serum Kyn/Trp ratios 
plus MELITAC 12.1 vaccine changes the level or character of the vaccine-induced CD8+ 
and CD4+ specific T-cell immune responses as measured in peripheral blood, as compared 
to prior published experience. 
 
13.5.2 To evaluate the extent to which INCB024360 plus MELITAC 12.1 vaccine alters the 
number and character of PBMC populations, including T and NK cells, as evaluated by 
multiparameter flow cytometry.  
 
13.5.3 To evaluate the extent to which INCB024360 plus MELITAC 12.1 vaccine alters the 
PBMC transcriptome.  
 
13.5.4 To assess the safety and tolerability of INCB024360 plus MELITAC 12.1 vaccine.  
 
13.5.5 To obtain preliminary data on the tumor response rate of INCB024360 plus MELITAC 
12.1 vaccine by ORR, time to tumor progression, and overall survival. 
 
13.5.6 To associate any observed changes with the expression of IDO1 protein by IHC in tumor or 
tumor-infiltrating cells. 
 
13.6 
Reporting and Exclusions 
 
13.6.1 Evaluation of Toxicity 
 
All patients will be evaluable for toxicity from the time of their first treatment with 
INCB024360. 
 
13.6.2 Evaluation of Response 
 
All patients included in the study will be assessed for response to treatment, even if major 
deviations from protocol treatment occur or if they are ineligible. Each patient will be 
assigned one of the following categories: (1) complete response,( 2) partial response, 
(3) stable disease, (4) progressive disease, (5) early death from malignant disease, (6) early 
death from toxicity, (7) early death because of other cause, or (9) unknown (not assessable, 
insufficient data).  
 
[NOTE: By arbitrary convention, category 9 usually designates the “unknown” status of 
any type of data in a clinical database.] 
 
All of the patients who met the eligibility criteria (with the possible exception of those who 
received no study medication) will be included in the main analysis of the response rate. 
Patients in response categories 4–9 will be considered to have a treatment failure (i.e., 
disease progression). Thus, an incorrect treatment schedule or drug administration does not 


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result in exclusion from the analysis of the response rate.  
 
All conclusions will be based on all eligible patients. Subanalyses may then be performed 
on the basis of a subset of patients, excluding those for whom major protocol deviations 
have been identified (e.g., early death due to other reasons, early discontinuation of 
treatment, major protocol violations, etc.). However, these subanalyses will not serve as the 
basis for drawing conclusions concerning treatment efficacy, and the reasons for excluding 
patients from the analysis will be clearly reported. The 95% confidence intervals will also 
be provided.  
 
 


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outcomes. Clin Cancer Res 7(10): 3012-3024. 
 
Soliman, H., M. Mediavilla-Varela, et al. (2010). Indoleamine 2,3-dioxygenase: is it an immune 
suppressor? Cancer J 16(4): 354-359. 
 
Speeckaert, R., K. Vermaelen, et al. (2012). Indoleamine 2,3-dioxygenase, a new prognostic 
marker in sentinel lymph nodes of melanoma patients. Eur J Cancer 48(13): 2004-2011. 
 
Suzuki, Y., T. Suda, et al. (2010). Increased serum kynurenine/tryptophan ratio correlates with 
disease progression in lung cancer. Lung Cancer 67(3): 361-365. 
 
Spranger, S., Bao, R., Gajewski, TF, (2015). Melanoma-intrinsic β-catenin signalling prevents 
anti-tumour immunity. Nature 523(7559):231-5 
 


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Gajewski, TF, Spranger, S., (2014) Synergistic combination of immunologic inhibitors for the 
treatment of cancer. US Patent 201466834 A1 
 
Tatsumi, K., T. Higuchi, et al. (2000). Induction of tryptophan 2,3-dioxygenase in the mouse 
endometrium during implantation. Biochem Biophys Res Commun 274(1): 166-170. 
 
Vergote, I., G. J. Rustin, et al. (2000). Re: new guidelines to evaluate the response to treatment in 
solid tumors [ovarian cancer]. Gynecologic Cancer Intergroup. J Natl Cancer Inst 92(18): 1534-
1535. 
 
Weiss, G. R., W. W. Grosh, et al. (2011). Molecular insights on the peripheral and intratumoral 
effects of systemic high-dose rIL-2 (aldesleukin) administration for the treatment of metastatic 
melanoma. Clin Cancer Res 17(23): 7440-7450. 
 
Wolchok, J. D., A. Hoos, et al. (2009). Guidelines for the evaluation of immune therapy activity in 
solid tumors: immune-related response criteria. Clin Cancer Res 15(23): 7412-7420. 
 
Yoshikawa, T., T. Hara, et al. (2010). Serum concentration of L-kynurenine predicts the clinical 
outcome of patients with diffuse large B-cell lymphoma treated with R-CHOP. Eur J Haematol 
84(4): 304-309. 
 
Zhang, G., W. L. Liu, et al. (2011). Involvement of indoleamine 2,3-dioxygenase in impairing 
tumor-infiltrating CD8 T-cell functions in esophageal squamous cell carcinoma. Clin Dev 
Immunol 2011: 384726 (epub). 
 
Zhao, Q., D. M. Kuang, et al. (2012). Activated CD69+ T cells foster immune privilege by 
regulating IDO expression in tumor-associated macrophages. J Immunol 188(3): 1117-1124. 
 
 


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APPENDIX A 
PERFORMANCE STATUS CRITERIA 
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work.
2 
In bed <50% of the time. 
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities. Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated. Death not imminent. 
4 
100% bedridden. Completely 
disabled. Cannot carry on any self-
care. Totally confined to bed or 
chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX B 
CTEP MULTICENTER GUIDELINES 
 
If an institution wishes to collaborate with other participating institutions in performing a 
CTEP sponsored research protocol, then the following guidelines must be followed. 
 
Responsibility of the Protocol Chair  
 The Protocol Chair will be the single liaison with the CTEP Protocol and Information 
Office (PIO). The Protocol Chair is responsible for the coordination, development, 
submission, and approval of the protocol as well as its subsequent amendments. The 
protocol must not be rewritten or modified by anyone other than the Protocol Chair. There 
will be only one version of the protocol, and each participating institution will use that 
document. The Protocol Chair is responsible for assuring that all participating institutions 
are using the correct version of the protocol. 
 The Protocol Chair is responsible for the overall conduct of the study at all participating 
institutions and for monitoring its progress. All reporting requirements to CTEP are the 
responsibility of the Protocol Chair in conjunction with the CITN Coordinating Center. 
 The Protocol Chair is responsible for the timely review of Adverse Events (AE) to ensure 
safety of the patients. 
 The Protocol Chair will be responsible for the review of and timely submission of data for 
study analysis. 
 
Responsibilities of the CITN Coordinating Center (Central Operations and Statistical Center, 
COSC) 
 Each participating institution will have an appropriate assurance on file with the Office for 
Human Research Protection (OHRP), NIH. The Coordinating Center is responsible for 
assuring that each participating institution has an OHRP assurance and verifies with CTSU, 
Regulatory Support System, (RSS) that each institution has obtained IRB approval prior to 
site activation.  
 Prior to the activation of the protocol at each participating institution, an OHRP form 310 
(documentation of IRB approval) must be submitted to CTSU, (RSS). 
 The Cancer Trials Support Unit is responsible for central patient registration through the 
OPEN registration system. The Coordinating Center is responsible for assuring that IRB 
approval has been obtained at each participating site before the first patient registration 
from that site. 
 The Coordinating Center is responsible for the preparation of all submitted data for review 
by the Protocol Chair. 
 The Coordinating Center will maintain documentation of AE reports. Participating 
institutions will report to the Coordinating Center who in turn report to CTEP or the FDA 
as appropriate. The Coordinating Center will submit AE reports to the Protocol Chair for 
timely review. 
 Audits may be accomplished by selecting a percentage of patient records on-site at 
participating sites. If the NCI chooses to have an audit at the Coordinating Center, then the 
Coordinating Center is responsible for having all source documents, research records, all 
IRB approval documents, NCI Drug Accountability Record forms, patient registration lists, 
response assessments scans, x-rays, etc. available for the audit. 
 


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Inclusion of Multicenter Guidelines in the Protocol  
 The protocol will include the following minimum information:  
 The title page must include the name and address of each participating institution and 
the name, telephone number and e-mail address of the responsible investigator at each 
participating institution. 
 The Coordinating Center must be designated on the title page. 
 Central registration of patients is required. The procedures for registration must be 
stated in the protocol. 
 Data collection forms should be of a common format. Sample forms should be 
submitted with the protocol. The frequency and timing of data submission forms to the 
Coordinating Center should be stated. 
 Describe how AEs will be reported from the participating institutions, either directly to 
CTEP or through the Coordinating Center. 
 Describe how Safety Reports and Action Letters from CTEP will be distributed to 
participating institutions. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX C 
INFORMATION ON POSSIBLE DRUG INTERACTIONS 
 
Information on Possible Interactions with Other Agents for Patients and Their Caregivers 
and Non-Study Healthcare Team 
 
 
The patient ____________________________ is enrolled on a clinical trial using the 
experimental agent INCB024360 (an IDO Inhibitor). This clinical trial is sponsored by the 
National Cancer Institute. This form is addressed to the patient, but includes important 
information for others who care for this patient.  
 
INCB024360 interacts with many drugs that are processed by your liver; it is very important to tell 
your study doctors about all of your medicine before you start this study. It is also very important 
to tell them if you stop taking any regular medicine, or if you start taking a new medicine while 
you take part in this study. When you talk about your medicine with your study doctor, include 
medicine you buy without a prescription at the drug store (over-the-counter remedy) or herbal 
supplements.  
 
Many healthcare prescribers can write prescriptions. You must also tell your other prescribers 
(doctors, physicians’ assistants or nurse practitioners) that you are taking part in a clinical trial. 
Bring this paper with you and keep the attached information card in your wallet. These are 
the things that you and they need to know:  
 
 
INCB024360 interacts with (a) certain specific enzyme(s) in your liver.  
 The enzyme(s) in question is UGT1A9. Hypothetically, inhibition of IDO could cause an 
increase in serotonin levels that could precipitate a cluster of adverse events termed 
serotonin syndrome. This rare syndrome has been associated with some MAO inhibitors 
and with combinations of serotonergic drugs. Symptom onset is usually rapid, often 
occurring within minutes, and encompasses a wide range of clinical findings: 
o Mild symptoms may only consist of increased heart rate, shivering, sweating, 
dilated pupils, and over-responsive reflexes.  
o Moderate symptoms may include additional abnormalities such as hyperactive 
bowel sounds, high blood pressure, and hyperthermia. A temperature as high as 
40°C (104°F) is common in moderate intoxication. Mental status changes include 
hypervigilance and agitation.  
o Severe symptoms include severe increases in heart rate and blood pressure that may 
lead to shock. In life-threatening cases, temperature may rise to above 41.1°C 
(106.0°F). Other abnormalities include metabolic acidosis, rhabdomyolysis, 
seizures, renal failure, and disseminated intravascular coagulation; these effects 
usually arise as a consequence of hyperthermia. 
 
 INCB024360 must be used very carefully with other medicines that need these liver 
enzymes to be effective or to be cleared from your system.  
 You and healthcare providers who prescribe drugs for you must be careful about adding or 
removing any drug in this category.  
 Before you start the study, your study doctor will work with your regular prescriber to 


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switch any medicines that are considered “strong inducers/inhibitors of UGT1A9 ” 
Inhibitors include acitretin, amitriptyline, androsterone, cyclosporine, dasatinib, diclofenac, 
diflunisal, efavirenz, erlotinib, estradiol (17-beta), flutamide, geftinib, gemfibrozil, 
glycyrrhetinic acid glycyrrhizin, imatinib, imipramine, ketoconazole, linoleic acid,  
mefenamic acid, mycophenolic acid, niflumic acid, nilotinib, phenobartital, 
phenylbutazone, phenytoin,  and probenecid propofol, quinidine, ritonavir, Sorafenib, 
sulfinpyrazone, valproic acid, and verapmil 
 Several patients on INCB024360 and coumadin (an anticoagulant blood thinner) have had 
elevated INRs, possibly from interactions with the CYP enzyme system. Thus, patients on 
coumadin should not be entered onto trial.  If coumadin needs to be administrated during or 
after the trial, INR needs to be monitored closely.  
 Your prescriber should consult a medical reference to see if any medicine they want to 
prescribe is on a list of drugs to avoid.  
 Please be very careful! Over-the-counter drugs have a brand name on the label—it’s 
usually big and catches your eye. They also have a generic name—it’s usually small and 
located above or below the brand name, and printed in the ingredient list. Find the generic 
name and determine, with the pharmacist’s help, whether there could be an adverse 
interaction.  
  Be careful:  
o If you take acetaminophen regularly: You should not take more than 2 grams per 
day on a regular or ongoing basis.  This is equal to approximately 6 regular strength 
tablets or 4 extra strength tablets per day. Read labels carefully! Acetaminophen is 
an ingredient in many medicines for pain, flu, and cold. 
o You should not be on anticoagulants (blood thinners) such as Coumadin.  
 
Other medicines can be a problem with your study drugs.  
 
 You should check with your doctor or pharmacist whenever you need to use 
an over-the-counter medicine or herbal supplement.  
 
 Your regular prescriber should check a medical reference or call your study 
doctor before prescribing any new medicine for you.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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86 
Your study doctor’s name is: 
 
_____________________________________  
 
and he or she can be contacted at  
 
_____________________________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
INFORMATION ON POSSIBLE DRUG INTERACTIONS  
You are enrolled on a clinical trial using the experimental agent 
INCB024360. This clinical trial is sponsored by the NCI. INCB024360 
interacts with drugs that are processed by your liver. Because of this, 
it is very important to: 
 Tell your doctors if you stop taking regular medicine or if you start 
taking a new medicine. 
 Tell all of your prescribers (doctor, physicians’ assistant, nurse 
practitioner, pharmacist) that you are taking part in a clinical trial. 
 Check with your doctor or pharmacist whenever you need to use 
an over‐the‐counter medicine or herbal supplement. 
 
INCB024360 might interact with a specific liver enzyme called 
UGT1A9, and must be used very carefully with other medicines that 
interact with this enzyme.  
 Before you start the study, your study doctor will work with your 
regular prescriber to switch any medicines that are considered 
“strong inducers/inhibitors or substrates of UGT1A9.” 
 
Before prescribing new medicines, your regular prescribers 
consult a medical reference to see if any medicine they want to 
prescribe is on a list of drugs to avoid or contact your study 
doctor.  
 Your study doctor’s name is _____________________________ 
and can be contacted at _________________________________.  


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APPENDIX D 
BIOASSAY TEMPLATES 
 
9.1.1.1 Tumor Biopsies 
 
9.1.1.2 Fine-Needle Aspiration (FNA) Biopsy of Tumor 
 
9.1.1.3 Blood for Serum and PBMC Isolation 
 
9.2.1 Immunohistochemical Evaluation of Tumor Biopsies—Laboratory Correlative Study #1 
 
9.2.2 Gene Expression Analyses of Tumor Biopsies, Fine Needle Aspirates of Metastases, and 
Peripheral Blood—Laboratory Correlative Study #2 
 
9.2.3 CD8+ T-Cell IFN-gamma Responses to the 12-Peptide Mixture, and CD4+ T-Cell Responses 
To Tetanus Peptide—Laboratory Correlative Study #3 
 
9.2.4 Quantification of PBMC and T-Cell Subsets—Laboratory Correlative Study #4 
 
9.2.5 Other Immunologic Assessments—Laboratory Correlative Study #5 
 
9.3 Special Studies: Cytokine and INCB024360 Blood Levels 
 
 
 


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APPENDIX E 
VACCINE PREPARATION 
 
12-MP + Tetanus Peptide Vaccine + Montanide ISA-51 VG 
Three (3) mL of emulsion will be prepared. Two (2) mL of this emulsion will be administered, with 1 mL 
administered at each of 2 vaccine sites. At each site, half of each dose (0.5 mL) will be injected 
subcutaneously and half (0.5 mL) will be injected intradermally. The remaining 1 mL of the prepared 
emulsion will be discarded.  
 
The 2 mL dose of each vaccine contains 100 μg each of the 12 peptides listed in Table 1 and 200 μg of 
tetanus peptide (Table 2), emulsified in 1 mL Montanide ISA-51 VG adjuvant. 
 
Vaccine composition: The peptides described in Tables 1–2 will be used in the vaccines. 
 
Table 1: 12 melanoma peptides (12-MP) 
Allele 
Sequence 
Epitope 
HLA-A1 
DAEKSDICTDEY 
Tyrosinase 240-251 * 
 
SSDYVIPIGTY 
Tyrosinase 146-156 
 
EADPTGHSY 
MAGE-A1 161-169 
 
EVDPIGHLY 
MAGE-A3 168-176 
HLA-A2 
YMDGTMSQV 
Tyrosinase 369-377  
 
IMDQVPFSV 
gp100 209-217 # 
 
YLEPGPVTA 
gp100 280-288 
 
GLYDGMEHL 
MAGE-A10 254-262 
HLA-A3/A11 
ALLAVGATK 
gp100 17-25 
 
LIYRRRLMK 
gp100 614-622 
 
SLFRAVITK 
MAGE-A1 96-104 
 
ASGPGGGAPR 
NY-ESO-1 53-62 
*(substitution of S for C at residue 244) 
(post-translational change of N to D at residue 371) 
#(209-2M, substitution of M for T at residue 210) 
 
Table 2: Tetanus toxoid-derived helper peptide 
 
 
 
**An alanine residue was added to the N-terminus to prevent cyclization. 
 
Materials 
Gloves (sterile) 
2–3 sterile gauze packets 
70% ethanol 
1 – 12-MP – “12 Melanoma Peptides from MDP and CTA”  [150 mcg each peptide per vial] 
1 – Tet – “Peptide-tet” [300 mcg peptide per vial] 
1 – Sterile water for injection 
1 – Sterile field 
1 - I connector 
3 – Alcohol swabs, 70% 
2 – 5-mL plastic syringe (Latex and silicon oil free and rubber tip free plunger) 
1 – 25-gauge 5/8" needle. A 27 gauge needle may be used for injection if desired. 
1 – 3-mL vial of Montanide ISA-51 VG (or larger) 
Allele 
Sequence
Epitope 
Binds to multiple class II alleles 
AQYIKANSKFIGITEL
p2830-844** 


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89 
2 – 19 gauge 1 ½ “needle 
1 – Cap from 15 ml conical tube filled with de-ionized water 
1 -- Ziploc bag 
3 -- Information labels 
 
General Preparation 
1. Remove 12-MP and Tet vials from the freezer. Each type of vial contains sterile lyophilized 
peptide. Thaw at room temperature (1–2 minutes). 
2. Turn on blower in hood. 
3. While wearing gloves, clean the hood with sterile gauze pads and 70% ethanol. 
4. Lay out the sterile field in the hood. 
5. Open the packages of sterile gauze packets.  Allow gauze to fall onto sterile field.  
6. Lay all other required items inside the hood (not on the sterile field). 
7. Remove the protective covers to expose the stoppers on the sterile water, 12-MP and Tet vials. 
8. Wipe the rubber stopper of the 12-MP, Tet and sterile water using a new alcohol swab for each 
vial. 
9. Place a 19 gauge needle on a plastic 5 mL syringe.  Uncap the needle and withdraw 1.5 ml of 
sterile water. 
10. Inject the 1.5 ml of sterile water into the 12-MP vial.  Swirl until dissolved.  This solution is 
now at 100 mcg/ml. 
11. Using the same 5 mL plastic syringe and needle, withdraw all of the 12-MP solution (1.5 ml). 
12. Inject the 1.5 ml of the 12-MP solution into the Tet vial. Swirl until dissolved. This now contains 
100 mcg/ml of each 12MP plus 200 mcg/ml of tetanus peptide. 
13. Using the same 5 mL plastic syringe and needle, withdraw all of the peptide solution (1.5 ml). 
Remove any air from the syringe and remove the needle. 
14. Remove a cap from the I-connector. Attach the syringe containing the peptide solution to the I-
connector. 
15. Lay the 5 mL syringe containing the peptide solution and I-connector on the sterile field. 
 
 
Montanide Preparation –  
16. Wipe the top of the vial of Montanide ISA-51 with an alcohol swab. 
17. Place a new 19 gauge needle on the second 5 mL syringe. Uncap the needle and withdraw 1.5 
ml of Montanide ISA-51.  
18. Remove the other cap from the I-connector. Attach the syringe containing the Montanide ISA-
51 to the I-connector. 
 
Mixing and Testing 
19. Hold the syringe/connector/syringe system firmly to guarantee a constant connection. Thumbs 
will be used to push the plungers apart. (To avoid any leak, do not push with both of the 
thumbs simultaneously). 
20. Push completely on the plunger of one of the syringes in order to get both phases in one 
syringe. 
21. Start to emulsify by transferring alternatively the formulation from one syringe to the other 
very slowly. 


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90 
22. The first 20 cycles (one cycle corresponds to the passage of the entire formulation from one 
container to the other through the connector and back) are done at slow rhythm. A complete 
cycle requires an average of 4 seconds. The 20 cycles should take 1 minute and a half. 
23. Once 20 cycles are complete, the speed is dramatically increased for 40 remaining cycles. This 
speed is as fast as possible. A timer can be set for 40 seconds to avoid losing count. 
24. Transfer the entire emulsion into one syringe. 
25. Disconnect the syringe from the connector. 
26. Twist a sterile 25 gauge needle onto the full syringe and drop 1-2 drops of the emulsion to a 
container of de-ionized water. If the drops disperse in the water, mix for an additional 40 
seconds and recheck as described. This test may be repeated twice. 
 
Preparing the vaccine for injection 
27. Inject excess emulsion (down to 2 ml in syringe) onto a sterile gauze pad. Tap on the syringe to void 
any bubbles. This 2 ml now contains 100 mcg of each of the 12MP plus 200 mcg of tetanus peptide 
plus 1 ml Montanide ISA-51 VG. 
28. Recap the needle and pull back on the piston slightly. 
29. Affix the patient information label to the syringe and add an additional label inside the Ziploc bag. 
30. Place the syringe into the Ziploc bag for transport and attach an additional label to the bag for 
identification 
 
Documentation & Clean-up 
31. Dispose of the syringes, needles, and vials in a contaminated materials container. Dispose of all other 
packaging in a regular trash can. 
32.  Complete paperwork. 
 
The remaining vaccine should be discarded. 
 
The prepared vaccine should be refrigerated until just before administration. Ideally, the vaccine should be 
administered within 1–2 hours after mixing. The vaccine must be administered within 4 hours of mixing. If 
the vaccine is not administered within 4 hours after mixing, it should be discarded.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX F 
PATIENT MEDICATION DIARY  
  
Patient ID: ____________________                   Site ID:  _______________________ 
 
Cycle:  ________________________ 
 
STUDY MEDICATION: INCB024360 
 
Date 
Time A.M. 
Time P.M.
Dose 
Pt. Initials 
Staff Initials 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient Signature:  ______________________________ Date:  ____________________ 
 
Staff Signature:  _______________________________ Date:  ____________________