A Two-arm, Single Center Phase 1b Trial of Bavituximab Plus Ipilimumab in Advanced Melanoma Patients

This is a Open label, two-arm, randomized, two agent, single center trial.

Study Product(s), Dose, Route, Regimen:

Bavituximab 3mg/kg IVqwk (IV every week) x 14 plus ipilimumab 3mg/kg IVq3wk (IV every 3
weeks) x 4 or ipilimumab 3mg/kg IVq3wk x 4

Administration Schedule:

Patients will be randomized to one of the following arms:

Arm A—Bavituximab 3mg/kg IV over 90 minutes weekly x 2 followed by Bavituximab 3mg/kg IV
over 90 minutes weekly x 12 plus ipilimumab 3mg/kg IV over 90 minutes every 3 weeks x 4.
Total number of treated patients will be 16.

Arm B—Arm B—Ipilimumab 3mg/kg IV over 90 minutes day 1 followed three weeks later by
ipilimumab every 3 weeks x 3. Total number of treated patients will be 8.

Randomization:

There will be a 2:1 randomization of patients to have a 3 week lead-in treatment with
bavituximab followed by combination therapy of ipilimumab + bavituximab versus ipilimumab
alone. The assigned treatment will be given once subject is registered successfully.

Endpoints:

Toxicities will be assessed via NCI's CTCAE (Common Terminology Criteria for Adverse Events)
v4.1 toxicity criteria. Dose limiting toxicities (DLTs) will be defined as drug-related
grade 3-5 adverse events experienced within the first 12 weeks of study treatment. The
maximal tolerated dose (MTD) will be exceeded if more than 30% of patients on the study
experience DLTs.

DCR will be measured by irRC (Immune-related Complete Response) at weeks 15, 21, 27 using
the published algorithm. Disease control rate (DCR) includes complete response (CR), Partial
response (PR) and stable disease (SD). Months of survival (MOS) is measured from date of
entry into protocol.

Tumor MDSC (Myeloid-Derived Suppressor Cells), TAM and Treg content will be measured by IHC
(ImmunoHistoChemistry). Circulating MDSC, TAM and Treg content will be measured by flow
cytometry.

Peripheral blood cytokines will be measured by EIA (EIA test is a series of blood tests for
diagnosing HIV infection).

Inclusion Criteria:

1. Histologic diagnosis of unresectable or metastatic melanoma. For unknown primary
disease, diagnosis of metastatic disease by cytology FNA (Fine Needle Aspiration) is
not acceptable.

2. Any number of prior systemic therapeutic regimens including chemotherapy, pathway
inhibitors, biochemotherapy, investigational agents, and immunotherapies other than
ipilimumab or bavituximab.

3. Subjects must have measurable disease as defined by irRC. All sites must be evaluated
within 4 weeks prior to beginning therapy.

4. Age ≥ 18 years.

5. Performance status ECOG (Eastern Cooperative Oncology Group) 0-2.

6. Adequate organ and marrow function as defined below:

- leukocytes ≥ 2,000/mcL (Microliter)

- absolute neutrophil count ≥ 1,500/mcL

- platelets ≥ 100,000/mcl

- total bilirubin < 3X (times) institutional upper limit of normal

- AST (Aspartate Aminotransferase) (SGOT)/ALT (Alanine Aminotransferase)(SPGT) ≤
2.5 X institutional upper limit of normal

- creatinine < 3X institutional upper limit of normal

- hemoglobin >8g/dL

7. Ability to understand and the willingness to sign a written informed consent.

8. Subjects must be willing to undergo tumor biopsy pretreatment and at weeks 3 and 15.

9. Women of child-bearing potential and men must agree to use adequate contraception
(hormonal or barrier method of birth control; abstinence) prior to study entry, for
the duration of study participation, and for 90 days following completion of therapy.
Should a woman become pregnant or suspect she is pregnant while participating in this
study, she should inform her treating physician immediately. A female of
child-bearing potential is any woman (regardless of sexual orientation, having
undergone a tubal ligation, or remaining celibate by choice) who meets the following
criteria: has not undergone a hysterectomy or bilateral oophorectomy; or has not been
naturally postmenopausal for at least 12 consecutive months (i.e., has had menses at
any time in the preceding 12 consecutive months).

Exclusion Criteria:

1. No concomitant therapy with any of the following: IL2 (Interleukin 2), interferon, or
other non-study immunotherapy regimens; cytotoxic chemotherapy; immunosuppressive
agents; other investigational therapies; or chronic use of systemic corticosteroids;
all such therapies must have been discontinued >4weeks.

2. No infection with HIV and no active infection with hepatitis B and no active or
chronic infection with hepatitis C. Due to the mechanism of action of ipilimumab,
activity and side effects in an immune compromised patient are unknown.

3. Subjects with active CNS (Central nervous system) disease are excluded. Patient with
brain metastases previously treated with surgery or stereotactic radiosurgery and
with confirmed SD for >8 weeks are allowed.

4. Subjects are excluded if they have a history of any other malignancy from which the
patient has been disease-free for less than 2 years, with the exception of adequately
treated and cured basal or squamous cell skin cancer, superficial bladder cancer or
carcinoma in situ of the cervix.

5. Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance with
study requirements.

6. Subjects must not be pregnant or nursing.

7. Any concurrent medical condition requiring the use of systemic steroids is not
permitted (the use of inhaled or topic steroids is permitted).

8. Subjects are excluded for receiving any non-oncology vaccine therapy used for
prevention of infectious diseases for up to 4 weeks (28 days) prior to or after any
dose of ipilimumab.

9. Subjects are excluded if they have a history of prior treatment with ipilimumab,
CD137 agonist , CTLA-4 inhibitor (Cytotoxic T-Lymphocyte Antigen 4) or agonist or
bavituximab.

10. Patients are excluded if they have a history of autoimmune disease except controlled
and stable autoimmune thyroiditis. The excluded autoimmune diseases include acute
disseminated encephalomyelitis, Addison's disease, alopecia universalis, ankylosing
spondylitis, antiphospholipid antibody syndrome, aplastic anemia, asthma, autoimmune
hemolytic anemia, autoimmune hepatitis, autoimmune hypoparathyroidism, autoimmune
hypophysitis, autoimmune myocarditis, autoimmune oophoritis, autoimmune orchitis,
autoimmune thrombocytopenic purpura, Behcet's disease, bullous pemphigoid, celiac
disease, chronic fatigue syndrome, chronic inflammatory demyelinating polyneuropathy,
Churg-Strauss syndrome, Crohn's disease, dermatomyositis, dysautonomia, eczema,
epidermolysis bullossa acquisita, gestational pemphigoid, giant cell arteritis,
Goodpasture's syndrome, Graves' disease, Guillain-Barre syndrome, Hashimoto's
disease-except as noted above, IgA nephropathy (Berger's disease), inflammatory bowel
disease, interstitial cystitis, Kawasaki's disease, Lambert-Eaton myasthenia
syndrome, lupus erythematosis, chronic Lyme disease, Meniere's syndrome, Mooren's
ulcer, Morphea, multiple sclerosis, myasthenia gravis, neuromyotonia, opsoclonus
myoclonus syndrome, optic neuritis, Ord's thyroiditis, pemphigus, pernicious anemia,
polyarteritis nodosa, polyarthritis, polyglandular autoimmune syndrome, primary
biliary cirrhosis, psoriasis, Reiter's syndrome, rheumatoid arthritis, sarcoidosis,
Sjogren's syndrome, Stiff-Person syndrome, Takayasu's arteritis, ulcerative colitis,
Vogt- Kovanagi-Harada disease, vulvodynia, and Wegener's granulomatosis.

11. Subjects are excluded with history of thromboembolic events, clinically significant
bleeding—gross hematuria, hemoptysis, or gastrointestinal bleeding, history of
bleeding diathesis or hypercoagulable state, ongoing therapy with anticoagulants or
non-steroidal anti-inflammatory drugs, or prior exposure to chimeric antibodies.