Neoadjuvant T-VEC in High Risk Early Melanoma

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62
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University of California, Davis

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Updated on 19 February 2024

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cancer

hysterectomy

platelet count

metastasis

neutrophil count

oophorectomy

tubal ligation

karnofsky performance status

primary tumor

hepatitis

systemic therapy

aptt

advanced melanoma

melanoma stage

immunotherapies

Summary

Despite the recent notable advances in the treatment of advanced melanoma with application of growing immunotherapies, patterns of response and factors resulting in treatment failure are poorly understood. Moreover, the application of these therapeutics has been limited in the neoadjuvant setting, particularly in earlier stage disease, even though this strategy has improved tolerance and efficacy with other modalities of therapy in other cancer types.

Survival remains significantly poorer for thicker and ulcerated lesions with T3b and T4 lesions demonstrating less than 50% survival at 5 years independent of other prognostic indicators. Oncolytic viral therapies (OVT) stimulate or suppress the immune system in different ways to stop cancer cells from growing and intra-lesional OVT has demonstrated comparable efficacy and durability with greater tolerability than most effective systemic therapy. Talimogene laherparepvec (T-VEC) is the only phase III approved intra-lesional therapy in melanoma and has demonstrated significantly improved overall response rate (64%) and bystander effect (34% in uninjected lesions) in the therapeutic setting for advanced disease.

The investigators propose an open-label, Phase 2 study of talimogene laherparepvec (T-VEC), in the neoadjuvant setting for patients with high-risk, resectable primary and cutaneous melanoma prior to definitive excision. The central hypothesis of this proposal is that neoadjuvant intra-lesional therapy with T-VEC in high risk early stage melanoma will effectively treat local and subclinical distant disease by enhanced immune recognition, immunomodulation of the nodal basin, and still allow for standard of care surgery. The primary aim of this study will be to evaluate for histologic response of melanoma with secondary aim to determine changes in immune response and draining sentinel nodes as well as relationship of immune phenotype to response rate, stage and nodal burden. The investigators plan for thorough exploratory analysis of genetic and microenvironmental changes to identify actionable targets in incomplete as well as evaluation of changes in sentinel burden and subsequent rates of locoregional disease control, recurrence-free survival and overall survival in long term follow up. The investigators predict that histologic clearance of the primary tumor in the surgical specimen will be associated with improved RFS.

In summary, the goal of this project is to conduct a phase II study to evaluate efficacy of Talimogene laherparepvec in the neoadjuvant setting for primary invasive melanoma in effort to improve currently poor outcomes for these tumors. This strategy has not yet been explored in early phase disease despite dramatic results seen with neoadjuvant therapeutics in other cancer types and recent clinical studies demonstrating efficacy of this approach in advanced resectable melanoma. Our ability to predict non-responder from responder to immunotherapeutic agents such as T-VEC is not yet defined and the risk of universal exposure to these systemic agents may outweigh the hypothesized benefit given the potential for immune-mediated toxicity as well as associated costs. More importantly, mechanistic dissection of pathways and molecular/immunological signatures of response and resistance offer the promise of a more rational and targeted selection of immunotherapy to maximize benefits and minimize risks. This study would be first in kind to target high earlier stage melanoma in the neoadjuvant setting with a less toxic intra-tumoral immunotherapy with key correlative endpoints regarding immune mechanisms of response.

Details

Condition	melanoma, Metastatic Melanoma, melanoma, skin cancer, skin cancer, Metastatic Melanoma
Age	18-100 years
Treatment	T-VEC
Clinical Study Identifier	NCT04427306
Sponsor	University of California, Davis
Last Modified on	19 February 2024

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Eligibility		Yes	No	Not Sure
Inclusion Criteria
	Ability to understand and willingness to sign an informed consent form
	Ability to adhere to the study visit schedule and other protocol requirements
	Men and women 18 years of age
	ECOG performance status score of 0-1 (Appendix 13.1) / Karnofsky Performance Status (KPS) performance status of 60% or greater
	Life expectancy 3 months
	Hematology parameters defined by
	Absolute neutrophil count (ANC) 1.5 109/L
	Platelet count 75 109/L, and
	Hemoglobin 8 g/dL (may have been transfused)
	Blood chemistry levels defined by
	Total bilirubin level 1.5 the upper limit of normal (ULN) range
	AST and ALT levels 2.5 ULN or AST and ALT levels 5 x ULN (for subjects with documented metastatic disease to the liver)
	INR and aPTT 1.5 x ULN (for patients on anticoagulation they must be receiving a stable dose for at least 1 week prior to first treatment)
	Creatinine clearance > 60 mL/min by Cockcroft-Gault formula
	Subjects with active hepatitis B virus (Hep B) and with untreated hepatitis C virus (HCV) are allowed
	Willingness to undergo mandatory pre-treatment biopsy (unless there is adequate archival tumor specimen available) and mandatory on-treatment biopsy
	Female subjects who are of non-reproductive potential (i.e., post-menopausal by history - no menses for 1 year; OR history of hysterectomy; OR history of bilateral tubal ligation; OR history of bilateral oophorectomy). Or, female subjects of childbearing potential must have a negative serum or urine pregnancy test within 72 hours prior to the first study drug administration
	Male and female subjects who agree to use highly effective method of birth control (e.g., implants, injectables, birth control pills with two hormones, intrauterine devices [IUDs], complete abstinence or sterilized partner, and female sterilization) and a barrier method (e.g., condoms, vaginal ring, sponge, etc.) during the period of therapy and for 90 days after the last dose of study drug
	Biopsy-proven resectable primary cutaneous melanoma > 2.0mm in depth with residual tumor or local, in-transit, or dermal oligometastatic resectable recurrence in a treatment- nave patient not otherwise eligible for systemic therapy
	Residual pigmented cutaneous lesion accessible to intralesional injection
Exclusion Criteria
	Pregnant or lactating women
	Any psychiatric condition that would prohibit the understanding or rendering of informed consent
	Any significant medical condition including additional malignancies, laboratory abnormalities, or psychiatric illness that would prevent the subject from participating and adhering to study related procedures
	Uncontrolled concomitant disease that in the opinion of the investigator would interfere with the patient's safety or compliance on trial
	Severe infection that in the opinion of the investigator would interfere with patient safety or compliance on trial within 4 weeks prior to enrollment
	Melanoma >/= 2.0mm in depth without residual disease following biopsy
	Previous exposure to talimogene laherparepvec or systemic therapies
	Concurrent cancer or treatment for a concurrent cancer, except treated non-melanoma skin cancer
	Regional or systemic metastases
	History of evidence of symptomatic autoimmune disease requires systemic treatment (ie, with use of disease modifying agents, corticosteroids or immunosuppressive drugs). Replacement therapy (eg, thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment
	Immunosuppressed state, including the following
	Primary immunodeficiency state such as Severe Combined Immunodeficiency Disease, concurrent opportunistic infection, receiving systemic immunosuppressive therapy (> 2 weeks) including oral steroid doses > 10 mg/day of prednisone or equivalent within 7 days prior to enrollment
	Prior immunosuppressive, chemotherapy, radiotherapy (in which the field encompassed a planned injection site), biological cancer therapy, or major surgery within 28 days prior to enrollment or has not recovered to CTCAE grade 1 or better from adverse event due to cancer therapy administered more than 28 days prior to enrollment
	Active human immunodeficiency virus (HIV) infection
	Active herpetic skin lesions or prior complication of herpes simplex virus-1 infection (e.g., herpetic keratitis or encephalitis)
	Current enrollment in another clinical trial
	Patients who are know to be sensitive to any of the products or components of T-VEC
	Requires intermittent or chronic systemic (intravenous or oral) treatment with an antiherpetic drug (e.g., acyclovir), other than intermittent topical use
	Previous treatment with talimogene laherparepvec or any other oncolytic virus
	Prior therapy with tumor vaccine or received live vaccine within 28 days prior to enrollment
	Adjuvant hormonal therapy is allowed if appropriate for planned study
	Prior radiotherapy in which the field does not overlap the injection sites or nonimmunosuppressive targeted therapy within 14 days prior to enrollment or has not recovered to CTCAE grade 1 or better from adverse event due to cancer therapy administered more than 14 days prior to enrollment
	History of other malignancy within the past 5 years with the following exceptions
	Adequately treated non melanoma skin cancer without evidence of disease at the time of enrollment
	Adequately treated cervical carcinoma in situ without evidence of disease at the time of enrollment
	Adequately treated breast ductal carcinoma in situ without evidence of disease at the time of enrollment
	Prostatic intraepithelial neoplasia without evidence of prostate cancer at the time of enrollment
	Subjects who are unwilling to minimize exposure with his/her blood or other body fluids to individuals who are at higher risks for HSV-1 induced complications such as immunosuppressed individuals, individuals known to have HIV infection, pregnant women, or infants under the age of 3 months, during talimogene laherparepvec treatment and through 30 days after the last dose

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Neoadjuvant T-VEC in High Risk Early Melanoma