A phase I/IIa clinical trial in stage IV melanoma of an autologous tumor-dendritic cell fusion (dendritoma) vaccine with low dose interleukin-2

BACKGROUND

Stage IV melanoma has high mortality, largely unaffected by traditional therapies. Immunotherapy including cytokine therapies and checkpoint inhibitors improves outcomes, but has significant toxicities. In this phase I/IIa trial, we investigated safety and efficacy of a dendritoma vaccine, an active, specific immunotherapy, in stage IV melanoma patients.

METHODS

Autologous tumor lysate and dendritic cells were fused creating dendritoma vaccines for each patient. Phase I patients were vaccinated every 3 months with IL-2 given for 5 days after initial inoculation. Phase IIa patients were vaccinated every 6 weeks with IL-2 given on days 1, 3 and 5 after initial inoculation. Toxicity and clinical outcomes were assessed.

RESULTS

Twenty-five patients were enrolled and inoculated. All dendritoma and IL-2 toxicities were

CONCLUSIONS

The dendritoma vaccine has minimal toxicity profile with potential clinical benefit. There was OS advantage for NED stage IV patients, those receiving higher number of doses and increased frequency. Based on these results, we initiated a phase IIb trial utilizing improved dendritoma technology in the adjuvant setting for NED stage III/IV melanoma patients.

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Key Words

• Adjuvant
• Dendritic cell
• Dendritoma
• Melanoma
• Vaccine

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MESH Headings

• Aged
• Arthralgia/chemically induced
• Cancer Vaccines/adverse effects
• Cancer Vaccines/immunology
• Cancer Vaccines/therapeutic use
• Chills/chemically induced
• Combined Modality Therapy
• Dendritic Cells/immunology
• Dendritic Cells/metabolism
• Dose-Response Relationship, Drug
• Drug Administration Schedule
• Erythema/chemically induced
• Female
• Humans
• Interleukin-2/adverse effects
• Interleukin-2/immunology
• Interleukin-2/therapeutic use
• Kaplan-Meier Estimate
• Male
• Melanoma/immunology
• Melanoma/therapy
• Middle Aged
• Nausea/chemically induced
• Neoplasm Recurrence, Local
• Neoplasm Staging
• Treatment Outcome

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Grants

• Greenville Hospital System

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Affiliation(s)

Julia M Greene General Surgery Department, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Joint Base San Antonio-Ft. Sam Houston, TX, USA
Erika J Schneble General Surgery Department, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Joint Base San Antonio-Ft. Sam Houston, TX, USA
Doreen O Jackson General Surgery Department, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Joint Base San Antonio-Ft. Sam Houston, TX, USA
Diane F Hale General Surgery Department, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Joint Base San Antonio-Ft. Sam Houston, TX, USA.
Timothy J Vreeland General Surgery Department, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Joint Base San Antonio-Ft. Sam Houston, TX, USA
Madeline Flores General Surgery Department, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Joint Base San Antonio-Ft. Sam Houston, TX, USA
Jonathan Martin General Surgery Department, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Joint Base San Antonio-Ft. Sam Houston, TX, USA
Garth S Herbert General Surgery Department, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Joint Base San Antonio-Ft. Sam Houston, TX, USA
Mark O Hardin General Surgery Department, Madigan Army Medical Center, 9040 Jackson Ave., Tacoma, 98431, WA, USA
Xianzhong Yu Clemson University, Clemson, SC, USA
Thomas E Wagner Perseus PCI, Greenville, SC, USA
George E Peoples Cancer Vaccine Development Program, 600 Navarro Street, Suite 500, San Antonio, TX, 78205, USA. Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.

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Future perspectives in melanoma research: meeting report from the "Melanoma Bridge": Napoli, December 3rd-6th 2014

The fourth "Melanoma Bridge Meeting" took place in Naples, December 3-6th, 2014. The four topics discussed at this meeting were: Molecular and Immunological Advances, Combination Therapies, News in Immunotherapy, and Tumor Microenvironment and Biomarkers. Until recently systemic therapy for metastatic melanoma patients was ineffective, but recent advances in tumor biology and immunology have led to the development of new targeted and immunotherapeutic agents that prolong progression-free survival (PFS) and overall survival (OS). New therapies, such as mitogen-activated protein kinase (MAPK) pathway inhibitors as well as other signaling pathway inhibitors, are being tested in patients with metastatic melanoma either as monotherapy or in combination, and all have yielded promising results. These include inhibitors of receptor tyrosine kinases (BRAF, MEK, and VEGFR), the phosphatidylinositol 3 kinase (PI3K) pathway [PI3K, AKT, mammalian target of rapamycin (mTOR)], activators of apoptotic pathway, and the cell cycle inhibitors (CDK4/6). Various locoregional interventions including radiotherapy and surgery are still valid approaches in treatment of advanced melanoma that can be integrated with novel therapies. Intrinsic, adaptive and acquired resistance occur with targeted therapy such as BRAF inhibitors, where most responses are short-lived. Given that the reactivation of the MAPK pathway through several distinct mechanisms is responsible for the majority of acquired resistance, it is logical to combine BRAF inhibitors with inhibitors of targets downstream in the MAPK pathway. For example, combination of BRAF/MEK inhibitors (e.g., dabrafenib/trametinib) have been demonstrated to improve survival compared to monotherapy. Application of novel technologies such sequencing have proven useful as a tool for identification of MAPK pathway-alternative resistance mechanism and designing other combinatorial therapies such as those between BRAF and AKT inhibitors. Improved survival rates have also been observed with immune-targeted therapy for patients with metastatic melanoma. Immune-modulating antibodies came to the forefront with anti-CTLA-4, programmed cell death-1 (PD-1) and PD-1 ligand 1 (PD-L1) pathway blocking antibodies that result in durable responses in a subset of melanoma patients. Agents targeting other immune inhibitory (e.g., Tim-3) or immune stimulating (e.g., CD137) receptors and other approaches such as adoptive cell transfer demonstrate clinical benefit in patients with melanoma as well. These agents are being studied in combination with targeted therapies in attempt to produce longer-term responses than those more typically seen with targeted therapy. Other combinations with cytotoxic chemotherapy and inhibitors of angiogenesis are changing the evolving landscape of therapeutic options and are being evaluated to prevent or delay resistance and to further improve survival rates for this patient population. This meeting's specific focus was on advances in combination of targeted therapy and immunotherapy. Both combination targeted therapy approaches and different immunotherapies were discussed. Similarly to the previous meetings, the importance of biomarkers for clinical application as markers for diagnosis, prognosis and prediction of treatment response was an integral part of the meeting. The overall emphasis on biomarkers supports novel concepts toward integrating biomarkers into contemporary clinical management of patients with melanoma across the entire spectrum of disease stage. Translation of the knowledge gained from the biology of tumor microenvironment across different tumors represents a bridge to impact on prognosis and response to therapy in melanoma.

Update on vaccines for high-risk melanoma

The management of high-risk melanoma has historically included primary surgical resection with or without lymphadenectomy followed by an array of adjuvant options including radiation therapy or immunomodulatory therapies such as interferon-α, granulocyte macrophage colony-stimulating factor, and a multitude of vaccines. There has been a long-standing interest in the development of vaccines in high-risk and metastatic melanoma, and clinical trials have been ongoing for decades. Given that melanoma is identified as one of the most immunogenic solid tumors, there is continued hope that vaccine therapies will improve clinical outcomes. Despite intense interest in this field, few clinical trials to-date have demonstrated significant benefit from melanoma vaccines in high-risk disease. Several trials have even documented a detrimental effect on outcomes after vaccine administration. While the role of vaccines in the adjuvant setting of high-risk melanoma presently remains unclear, recent advances in immunotherapy for melanoma including development of cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death 1 (PD-1) monoclonal antibodies have demonstrated meaningful clinical responses. With further study and focus on mechanisms of immune regulation, there remains promise for the role of vaccines in combination with other immune-stimulatory agents in high-risk melanoma.

Advances in the management of melanoma: targeted therapy, immunotherapy and future directions

Metastatic melanoma is an aggressive, immunogenic and molecularly heterogeneous disease for which most patients require systemic treatment. Recently, significant clinical breakthroughs have revolutionized the treatment of advanced melanoma, leading to the licensing of ipilimumab, a monoclonal antibody targeting cytotoxic T-lymphocyte-associated antigen 4, and vemurafenib, a BRAF inhibitor used in patients whose tumors contain a V600 mutation in the BRAF gene. This recent success has led to optimism and momentum has gathered with updated trial results from these therapies, next-generation compounds that target validated molecular pathways and novel agents that are mechanistically distinct. This review summarizes the recent advances and updated results since the licensing of vemurafenib and ipilimumab, the benefits and limitations of these agents, future strategies to improve upon existing treatments and overcome acquired resistance, in-progress and future clinical trials, as well as novel therapeutic targets, pathways and therapies that hold promise in advancing clinical benefit.

Cancer vaccines: should we be targeting patients with less aggressive disease?

There is enthusiasm for using vaccines to stimulate the immune system to treat cancer. In this article, the authors review the evolution of vaccines evaluated in clinical trials, starting with Phase III trials in metastatic disease and progressing to trials in the adjuvant setting. Data from these trials suggest that cancer vaccines may be more effective in patients with lower volume disease, and data from the E75 peptide vaccine trials suggest that vaccines may be most effective in less aggressive disease.

Management of pegylated interferon alpha toxicity in adjuvant therapy of melanoma

INTRODUCTION

Both native IFNα2b and pegylated IFNα2b (PegIFNα2b) are approved for the adjuvant treatment of high-risk melanoma.

AREAS COVERED

This review compares the toxicity profiles of high-dose IFNα2b (HDI) and PegIFNα2b, and provides recommendations on the management of common PegIFNα2b-related toxicities, based on available clinical data and published literature.

EXPERT OPINION

The toxicity profile of PegIFNα2b at the approved dose (6 μg/kg/week for 8 weeks then 3 μg/kg/week for up to 5 years) is qualitatively similar to HDI in melanoma. The most common adverse events (AEs) are fatigue, anorexia, hepatotoxicity, flu-like symptoms, injection site reactions and depression. However, fatigue and flu-like symptoms appear less severe with PegIFNα2b, and toxicity seems to occur earlier, whereas with HDI toxicity may increase with time. Most AEs can be managed effectively by dose modification and aggressive symptom control. Dosing to tolerance using a three-step dose reduction schedule to maintain an ECOG performance status of 0 - 1 may enable patients experiencing toxicity to remain on treatment; this can be applied readily in clinical practice. PegIFNα2b is therefore a valuable alternative option for adjuvant treatment in melanoma, with a toxicity profile similar to that of HDI overall but a more convenient administration schedule.