Evaluating the Safety and the Biological Effects of Intratumoral Interferon Gamma and a Peptide-Based Vaccine in Patients With Melanoma

Melanoma vaccines have been associated with major regressions in a small percentage of
patients with advanced measurable disease. This provides proof-of-principle of the potential
for clinical benefit with melanoma vaccines however, the current response rate is low. Thus,
there is a critical need for additional new therapies for melanoma, both for adjuvant
therapy of high-risk resected melanoma and for therapy of patients who are not candidates
for, or fail, other therapies in the setting of advanced disease.

It is generally agreed that one mechanism to improve the immunologic outcomes of vaccine
therapy is to optimize T cell trafficking to the tumor site. CXCR3 is the chemokine receptor
on T cells which directs them to sites of inflammation by following the chemokine gradient.
The ligands for CXCR3 (CXCL9 (MIG), CXCL10 (IP-10) and CXCL11 (I-TAC)) are known to be
induced by interferon gamma. This protocol proposes administering a peptide vaccine to
activate tumor antigen-specific CD8+ T cells expressing CXCR3, followed by intratumoral
interferon gamma to increase CXCR3 ligands (CXCL9-11) at the tumor site and recruit the
CXCR3+ T cells.

The primary goals of the proposed work are to assess the safety of the combination of
peptide vaccine and intratumoral interferon gamma and to assess the immunologic outcomes at
the tumor site.

Inclusion Criteria:

1. Participants with stage IIIB, IIIC or IV melanoma. Staging must be confirmed by
cytological or histological examination. Staging of cutaneous melanoma will be based
on the revised AJCC staging system.

2. Patients must have adequate cutaneous or subcutaneous metastases of melanoma readily
accessible for biopsy to provide a minimum of 0.3 cm3 of tissue per biopsy
(approximately 0.85 cm by 0.85 cm x 0.85 cm or five 2mm core biopsies) at each time
point. Additionally, at least one of the subcutaneous or cutaneous metastases must be
accessible to intratumoral IFN-gamma administration. Several scenarios may fulfill
the tumor burden requirement. For example, a patient may have one large lesion from
which core biopsies can be taken for the first and second biopsy time points and then
the entire lesion excised for the final tissue sample. Alternatively, a patient may
have three lesions, each ≥0.3 cm3, and these lesions would be excised sequentially as
biopsies 1, 2 and 3. Other combinations are acceptable.

The intent is to limit this study to patients with cutaneous or subcutaneous melanoma
metastasis rather than lymph node metastasis. There may be cases where a subcutaneous
nodule cannot be definitively characterized as a non-nodal metastasis at the start of
the trial - these patients may be included.

3. Participants with ocular, mucosal or unknown primaries and participants with multiple
primaries will be eligible.

4. Participants who have had brain metastases may be eligible in selected circumstances:

Patients with less than or equal to 3 metastases may eligible as long as the
following 3 criteria are true:

- The brain metastases have been completely removed by surgery or have been
treated completely by stereotactic radiotherapy. Stereotactic radiotherapy, such
as gamma knife, can be used up to 1 week prior to study entry.

- There has been no evident growth of any brain metastasis since treatment.

- No metastasis greater than 2 cm at the time of protocol entry

Patients with greater than 3 metastases may be eligible if the above 3 criteria are
met and if at least one year has elapsed since the last treatment.

5. All participants must have:

- ECOG performance status of 0 or 1

- Ability and willingness to give informed consent

6. Laboratory parameters - The following laboratory parameters will be required for all
participants. If a lab value appears to be an error or a result of a transient or
treatable condition, the investigator will use his/her clinical judgment to decide if
the test may be repeated. The requirements for inclusion are as follows:

- HLA-A1, -A2, -A3, or -A11+

- ANC > 1000/mm3

- Platelets > 100,000/mm3

- Hgb > 9 g/dL

- HGBA1C < 7%

- Hepatic:

- AST and ALT ≤ 2.5 x upper limits of normal (ULN)

- Bilirubin ≤ 2.5 x ULN

- Alkaline phosphatase ≤ 2.5 x ULN

- Renal

o Creatinine ≤ 1.5 x ULN

- Serology (within 6 months of study entry)

- HIV negative

- Hepatitis C negative

- LDH up to 2 x ULN

7. Age 18 years or older at the time of trial entry

8. Participants must have at least one intact (undissected) axillary and/or inguinal
lymph node basin

Exclusion Criteria:

1. Patients who have had brain metastases unless they meet the criteria outlined above
in the inclusion criteria.

2. Patients who are currently receiving systemic cytotoxic chemotherapy, radiation, or
other experimental therapy, or who have received this therapy within the preceding 4
weeks. Gamma knife or stereotactic radiosurgery may be administered within the prior
4 weeks, but must not be administered less than one week prior to study enrollment.
Patients who are currently receiving nitrosoureas or who have received this therapy
within the preceding 6 weeks.

3. Patients will not be eligible if there is clinically detectable melanoma deemed
likely by the investigator to require intervention during the first 3 months of the
study that would require premature discontinuation. Examples for such circumstances
may include untreated bone metastases at risk for fracture, and rapidly progressive
low volume disease.

4. Patients with known or suspected allergies to any component of the vaccine.

5. Patients receiving the following medications at study entry or within the preceding 4
weeks are excluded:

- Agents with putative immunomodulating activity (with the exception of
non-steroidal anti-inflammatory agents and topical steroids)

- Allergy desensitization injections.

- Systemic corticosteroids, administered parenterally or orally. Inhaled steroids
(e.g. Advair®, Flovent®, Azmacort®) are not permitted. Topical corticosteroids
are acceptable, including steroids with very low solubility administered nasally
for local effects only (e.g. Nasonex®).

- Any growth factors (e.g. GM-CSF, G-CSF, erythropoietin).

- Interferon therapy

- Interleukin-2 or other interleukins.

6. Prior melanoma vaccinations may be an exclusion criterion in some circumstances:

- Patients who have recurred or progressed either after or during administration
of a melanoma vaccine may be eligible to enroll 12 weeks following their last
vaccination.

- Patients may have been vaccinated previously with peptide vaccines (including
MELITAC 12.1 and similar vaccines) or with non-peptide vaccines.

7. Other investigational drugs or investigational therapy if the patient is currently
taking those drugs/therapy, or if they have received the drugs/therapy within 1
month.

8. Pregnancy or the possibility of becoming pregnant during vaccine administration.
Female patients of child-bearing potential must have a negative pregnancy test
(urinary or serum beta-HCG) prior to administration of the first vaccine dose. Males
and females must agree, in the consent form, to use effective birth control methods
during the course of vaccination. Women must also not be breast feeding. This is
consistent with existing standards of practice for vaccine and chemotherapy
protocols.

9. Patients in whom there is a medical contraindication or potential problem in
complying with the requirements of the protocol, in the opinion of the investigator.

10. Patients classified according to the New York Heart Association classification as
having Class III or IV heart disease.

11. Patients with a body weight < 110 lbs because of the amount and frequency with which
blood will be drawn

12. Participants must not have had prior autoimmune disorders requiring cytotoxic or
immunosuppressive therapy, or autoimmune disorders with visceral involvement.
Participants with an active autoimmune disorder requiring these therapies are also
excluded. The following will not be exclusionary:

- The presence of laboratory evidence of autoimmune disease (e.g. positive ANA
titer) without symptoms

- Clinical evidence of vitiligo

- Other forms of depigmenting illness

- Mild arthritis requiring NSAID medications