Combining Talimogene Laherparepvec With BRAF and MEK Inhibitors in BRAF Mutated Advanced Melanoma

While targeted therapies can successfully block oncogenic signaling in BRAF mutant melanoma,
activation of an immune response with agents such as talimogene laherparepvec can induce
durable responses in a subset of patients. Combining BRAF inhibitors and immunotherapy may
specifically target the BRAF driver mutation in the tumor cells and potentially sensitize the
immune system to target tumors.

The study will enroll up to 20 patients with advanced melanoma and activating mutations in
the BRAF gene for the local administration of talimogene laherparepvec in conjunction with
oral therapy with dabrafenib and trametinib, to describe the safety and tolerability of this
combination.

Talimogene laherparepvec will be administered by intralesional injection into injectable
cutaneous, subcutaneous, or nodal lesions with or without image ultrasound guidance.
Talimogene laherparepvec will not be administered into any visceral organ or mucosal membrane
lesions. The initial dose of talimogene laherparepvec is up to 4.0 mL of 106 plaque forming
units (PFU)/mL. Subsequent doses of talimogene laherparepvec are up to 4.0 mL of 108 PFU/mL.
The second dose of talimogene laherparepvec (the first dose of the 108 PFU formulation), will
be administered at least 21 days following the initial dose. Subsequent doses will be given
approximately every 2 weeks.

Dabrafenib at a dose of 150mg will be self-administered orally twice per day. Trametinib at a
dose 2mg will be self-administered orally once per day.

Subjects will be evaluated by physical exam at the beginning of Cycle 1 (Week 1), Cycle 2
(Week 4), Cycle 3 (Week 6), Cycle 4 (Week 8), and every two cycles thereafter. Subjects will
be evaluated for dose-limiting toxicities (defined in protocol) at Cycle 2 (Week 4), Cycle 3
(Week 6), and Cycle 4 (Week 8). Efficacy evaluation will be performed by tumor measurements
using clinical assessment, CT or PET/CT every 4 cycles with the first non-baseline
measurement prior to Cycle 4. Tumor response will be evaluated using RECIST 1.1. Adverse
events will be recorded and graded using the Common Terminology Criteria for Adverse Events
Version 4.0 (CTCAE v4.0). Other safety assessments will include clinical laboratory values
and physical exam findings. Reporting of adverse events, serious adverse events, and
documentation of concomitant medications will occur as needed and at every cycle. Biopsy of a
melanoma lesion (preferably uninjected) should occur at least one day prior to Cycle 4 (Week
8). Blood for biomarker analysis will be obtained immediately prior to the on-treatment
biopsy, or if the on-treatment biopsy cannot be performed, immediately prior to Cycle 4 (Week
8).

Inclusion Criteria:

1. Age ≥ 18

2. Primary or recurrent Stage IIIB to IVM1c melanoma for whom surgery is not recommended

3. Activating BRAF mutation (limited to V600E or V600K mutations if being treated
first-line, but can include any well-defined BRAF mutation after failure of prior
immunotherapy)

4. Measurable disease defined as follows: At least one melanoma lesion that can be
accurately and serially measured in one dimension and for which the longest diameter
is ≥10 mm as measured by calipers, CT scan, or MRI.

a. If all lesions are lymph nodes, at least one node must be able to be accurately and
serially measured in two dimensions, and the short-axis must be ≥15mm.

5. Injectable disease (defined as at least 1cm of disease in areas suitable for injection
including cutaneous, subcutaneous, or nodal lesions)

Exclusion Criteria:

1. Prior therapy with talimogene laherparepvec

2. Prior therapy with the combination of dabrafenib and trametinib

3. Evidence of clinically significant immunosuppression such as the following:

1. Primary immunodeficiency state such as Severe Combined Immunodeficiency Disease

2. Concurrent opportunistic infection

3. Receiving chronic systemic immunosuppressive therapy (> 2 weeks), including oral
steroid doses > 10mg/day of prednisone or equivalent except for management of
adverse events and CNS metastases during the course of the study. Subjects
requiring intermittent use of bronchodilators or local steroid injections are not
excluded.

4. Active herpes infection, herpes requiring chronic anti-herpetic therapy, or
complications of prior herpetic infection (such as keratitis or encephalitis)

5. Chronic use of immunosuppressants or steroids (defined as prednisone 10mg/day or
equivalent)

6. Clinically active cerebral metastases

7. History or evidence of melanoma associated with immunodeficiency states

8. History of other malignancy within prior 24 months with the exception of breast or
bladder carcinoma in situ, and non-melanomatous skin cancer