High-Risk Melanoma Clinical Trial
Official title:
Evaluation of the Impact of Adjuvants Accompanying Peptide Immunization in High Risk Melanoma
This study will evaluate the immunization effects of a vaccine for patients who are at risk
for recurrence of their skin cancer. That is, the risk of cancer is higher if melanoma has
invaded deep into the skin or lymph nodes. Currently, the only therapy that the U.S. Food
and Drug Administration (FDA) has approved for preventing recurrence of melanoma is
alpha-interferon. But the research data are controversial. In this study, the vaccine to be
used, called gp100, contains a piece of a protein called a peptide, which melanoma cancer
cells produce.
Patients 16 and older who have had confirmed melanoma surgically removed and whose tissue
type is tested as being human leukocyte antigen serotype within HLA-A serotype group
(HLA-A2), through a specific blood test, may be eligible for this study.
Up to 132 participants will be enrolled. There will be a physical examination and collection
of blood samples for tests, and making sure that x-rays and scans are current. Patients will
be randomly assigned to four groups. Group 1 will receive the peptide with an adjuvant
(assistant) oil-based liquid called Montanide ISA-51, as an injection in the thigh. Group 2
will receive gp100, Montanide, and a cream called imiquimod, which the FDA has approved for
treating genital warts and herpes but that may help immune cells in the skin to recognize
the vaccine. Imiquimod will be applied to the skin for 5 days. Group 3 will receive gp100
mixed in salt water given as several mini-doses under the skin of the thigh. Group 4 will
also receive several mini-doses of gp100 mixed in saline, as well as imiquimod cream applied
to the skin for 5 days. All patients will receive the gp100 every 3 weeks for 12 weeks.
Every dose is a cycle, with four cycles considered a course of therapy. If the melanoma does
not return or patients do not experience side effects from this therapy, then the courses of
vaccine will repeated for up to 12 cycles of therapy (3 courses over 33 weeks). Side effects
of the peptide vaccination include local swelling, swelling of local lymph nodes, bruising,
and pain and redness at the injection sites. There may be chills or fever. Patients will be
watched closely for such side effects.
To study how the vaccine changes the action of cells in the immune system, patients' white
blood cells (lymphocytes) will be obtained, involving a separate informed consent. The
procedure, called leukaphersis, requires inserting a needle into the arm, to obtain blood
going into a machine, which divides the blood into red cells, plasma (or the serum part),
and lymphocytes. The lymphocytes are removed, and the plasma and red cells returned to the
patient through a second needle in the other arm. Risks associated with the procedure
include fainting, which can be prevented by patients' eating before coming to the lab, and
bleeding and infection at the needle site. Patients will undergo leukapheresis will be done
about four times: before receiving the vaccine, 3 weeks after the first four doses, and then
after 8 cycles and 12 cycles. Patients assigned to the groups receiving imiquimod will be
asked to record every time they apply that cream and describe any symptoms developed during
the study. All patients will be watched closely for any sign that their melanoma has
returned. Before and throughout the study, multiple blood tests will be conducted.
The vaccine, Montanide, and imiquimod may increase patients' immune system in fighting off
new tumors, but that is not known now. However, the study may provide information that will
be useful in treating melanoma patients in the future.
Background:
A previous clinical trial has been conducted in the Surgery Branch National Cancer Institute
(NCI) in which gp100 immunizations have been administered to patients with melanoma in the
adjuvant setting. In this prior protocol, the peptide emulsified in Incomplete Freund's
Adjuvant was administered subcutaneously using several different schedules and was well
tolerated except for mild and transient erythema at the site of injection. Each of the
schedules provided successful immunization although the q3w schedule was the best tolerated
locally and three courses of immunization appeared to be sufficient using this regimen. An
important finding from the adjuvant protocol however was the significant increase in immune
precursors specifically reactive against peptide and tumor that occurred with increasing
courses of immunization. These findings have encouraged us to now further explore the
optimal methods for generating immune precursors using the gp100:209-217(210M) peptide by
testing the impact of an additional immune adjuvant, imiquimod, reported to increase the
immunizing potential of antigens as well as evaluate an alternate route of injection,
intradermal administration.
Objectives:
The primary objective of this trial is to evaluate the immunologic activity of immunization
with four different preparations of the gp100:209-217(210M) melanoma antigen peptide and
potentially select one for further study.
Eligibility:
HLA-A 0201 patients, age greater than or equal 16 years, with primary melanomas with lesions
that are ulcerated and greater than or equal 2mm, or any lesions that are greater than or
equal 4.0 mm in thickness, or greater than or equal 1 positive lymph node, or local
recurrence, or resected metastatic disease, within 6 months of surgical resection will be
considered. Patients who have ocular or mucosal melanoma or who require systemic steroid
therapy will be excluded. The following patients will also be excluded: have previously been
immunized with gp100; have known hypersensitivity to any of the agents used in this study;
have previously received chemotherapy for treatment of melanoma; or who are undergoing or
have undergone in the past 3 weeks any systemic therapy except surgery for their cancer.
Design:
Patients will be randomized into one of the following four arms:
1. gp100:209-217(210M) peptide emulsified in MONTANIDE ISA-51 or Montanide ISA 51 VG
injected subcutaneously on day one every three weeks (1 cycle) for a total of twelve
cycles (33 weeks).
2. gp100:209-217(210M) peptide emulsified in MONTANIDE ISA-51 or Montanide ISA 51 VG
injected subcutaneously on day one every three weeks (1 cycle) for a total of twelve
cycles (33 weeks); following the injection patients will apply imiquimod to the skin at
the site of injection daily for 5 days.
3. gp100:209-217(210M) in 0.9% Sodium Chloride Injection injected intradermally on day one
every three weeks (1 cycle) for a total of twelve cycles (33 weeks).
4. gp100:209-217(210M) peptide in 0.9% Sodium Chloride Injection injected intradermally on
day one every three weeks (1 cycle) for a total of twelve cycles (33 weeks); following
the injection patients will apply imiquimod to the skin at the site of the injection
daily for 5 days.
Immunizations will be administered on an outpatient basis unless side effects or the
patient's clinical condition warrants hospitalization. Patients will receive full clinical
evaluation three weeks after 8 cycles and 12 cycles.
Each of the arms will be conducted using a two-stage optimal design Since the primary
objective is to select one regimen from among the four on the basis of the immune response,
this design allows there to be greater than 80% probability of correctly selecting the
superior arm if there is either a tie in the number of immune responses, or if there is at
least one more immune response on one arm than the other three arms, and if the true
response rates are 15%, 15%, 15% and 35%. Initially, 19 patients will be enrolled in each
arm and evaluated; if 0 to 3 of 19 in an arm have an immune response to T2 cells pulsed with
0.01 M peptide after the 4th, 8th, and 12th cycles, no further patients would be randomized
to receive the peptide on that arm. If at least four immunologic responses are noted after
the 8th cycle, then accrual to 33 patients would take place. If all four arms need to be
completed and 33 patients need to be completed in each arm, a total of 132 patients are
required.
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Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment