Study to Assess Safety and Immune Response of Stage IIB-IV Resected Melanoma After Treatment With MAGE-A3 ASCI

This was an open-label randomized single institution pilot study to evaluate the safety and
immunologic response to MAGE-A3 immunotherapeutic administered by either of two injection
routes (i.m. or i.d./s.c.). Patients were studied following IRB approval (IRB #15398) and
documentation of informed consent. The trial was registered in clinicaltrials.gov
(NCT01425749), and was performed at the University of Virginia.

MAGE-A3 immunotherapeutic (0.5 ml) was administered five times (weeks 0, 3, 6, 9, 12) in
extremities uninvolved with melanoma. Vaccines 1 and 3 were administered at the same site:
other vaccine sites were rotated among available extremities. Subjects were randomized 1:1,
within each stratum (AJCC stage II/III or IV), to i.m. (Group A) or i.d./s.c. (Group B)
administration. The randomization code was generated by the study statistician using varying
block sizes of 2 to 4. For group B patients, half of the dose was injected s.c., then the
needle was withdrawn to the dermis, then advanced intradermally from that same puncture site
and the remaining half dose was injected i.d. Immune responses were evaluated in a SIN and
PBMC.

Inclusion Criteria:

- Histologically or cytologically proven melanoma that meets one of the following two
criteria:

- Stage IIB-IV melanoma rendered clinically free of disease by surgery, other
therapy, or spontaneous remission within 6 months prior to registration.

- Stage III or IV melanoma with disease. Patients may be eligible if there are
definite or equivocal findings of persistent or metastatic disease as long as
those findings do not meet RECIST criteria for measurable disease.

- Expression of MAGE-A3 by the tumor (primary or metastasis).

- Patients may have had multiple primary melanomas.

- Patients may have had, or may have, a metastasis from a cutaneous, mucosal, unknown
primary site.

- Patients with brain metastases may be eligible if all of the following are true:

- The total number of brain metastases ever is less than or equal to 3.

- 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 treated brain metastasis is greater than 2 cm in diameter at the time of
protocol entry.

- Patients must have at least two intact axillary and/or inguinal lymph node basins.

- The interferon education packet must be completed satisfactorily for those who are
eligible for, but refuse, interferon therapy.

- All patients must have:

- ECOG performance status of 0 or 1.

- Ability and willingness to give informed consent.

- Laboratory parameters as follows:

1. ANC > 1000/mm3, and Platelets > 75,000/mm3 and Hgb > 9 g/dL

2. Hepatic:

AST and ALT up to 2.5 x upper limits of normal (ULN) Bilirubin up to 2.5 x ULN
Alkaline phosphatase up to 2.5 x ULN LDH up to 2x ULN

3. Renal:

Creatinine up to 1.5 x ULN

4. Serology:

HIV negative (antibody screening), Hepatitis C negative

5. HGBA1C level of < 7.5%

- Patients must be 18 years or older at study entry

Exclusion Criteria:

- Patients with primary ocular melanoma.

- Patients who have had brain metastases unless they meet the criteria outlined in the
inclusion criteria

- Patients who are currently receiving systemic cytotoxic chemotherapy, radiation,
monoclonal antibody therapy, or other experimental therapy, or who have received this
therapy within the preceding 4 weeks. Patients who are currently receiving
nitrosoureas or who have received this therapy within the preceding 6 weeks.

- Patients who have received isolated limb infusion (ILI) or isolated limb perfusion
(ILP) for melanoma will not be eligible unless they have experienced tumor
progression after the ILI/ILP, and the ILI/ILP was not performed within the prior 12
weeks.

- Patients will not be eligible if there is clinically detectable melanoma deemed
likely by the investigator to require intervention during the first 12 weeks of the
study that would require premature discontinuation.

- Patients with known or suspected allergies to any component of the MAGE-A3 ASCI.

- Patients receiving the following medications at study entry or within the preceding 4
weeks are excluded, except as specified below:

1. Agents with putative immunomodulating activity, but with the exception of
non-steroidal anti-inflammatory agents and topical steroids.

2. Antibodies to CTLA-4, PD-1, PD-L1, or CD137 may not have been received in the
past 12 weeks, and patients will be eligible only if there has been melanoma
progression since that therapy was administered.

3. Allergy desensitization injections.

4. Systemic corticosteroids, administered parenterally or orally. Inhaled steroids
are not permitted. Topical corticosteroids are acceptable, including steroids
with very low solubility administered nasally for local effects only.

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

6. Interferon therapy.

7. Interleukin-2 or other interleukins.

8. Targeted therapies designed to inhibit BRAF, MAPKinase, mTOR, or their signaling
pathways.

- Prior active immunotherapy or vaccines for melanoma may be an exclusion criterion in
some circumstances. Exceptions to this exclusion criterion are as follows:

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

2. Patients may not have been previously administered the synthetic MAGE-A3
protein, though prior vaccinations with up to 4 synthetic MAGE-A3 peptides (up
to 16 amino acids in length, each) is allowed.

- 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 MAGE-A3 ASCI 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.

- 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.

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

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

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

- 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