A Phase 2, Three-arm, Randomized Study of the Efficacy of Intratumorally Administered L19IL2 or L19TNF or L19IL2/L19TNF, All in Combination with Systemic Anti-PD1 Pembrolizumab, in Stage III and IV Unresectable Melanoma Patients with Resistance to or Progressing Upon Anti-PD1 Checkpoint Inhibitors and with Presence of Injectable Metastases
Summary
The trial aims to evaluate the efficacy of single agent L19IL2, single agent L19TNF, and combination L19IL2+L19TNF given concurrently with anti-PD1 therapy compared to historical control of anti-PD-1 re-challenge alone for anti-PD1 refractory unresectable stage III-IV melanoma.
Detailed description
The present study is a randomized, open-label, three-arm, parallel phase 2 study. A Simon two-stage design for the study of the efficacy of intralesional therapy with L19IL2 or L19TNF or L19IL2/L19TNF in combination with systemic anti-PD1 pembrolizumab immunotherapy will be used. In the study, 162 patients will be randomized in a 1:1:1 ratio to receive: i) systemic pembrolizumab in combination with intralesional L19IL2 (Arm 1) or ii) systemic pembrolizumab in combination with intralesional L19TNF (Arm 2) or iii) systemic pembrolizumab in combination with intralesional L19IL2/L19TNF (Arm 3). This is an open-label study, so there is no blinding. The study consists of a two-week screening period, followed by a 4-weeks open-label intralesional treatment period with immunocytokines (ICKs) either L19IL2, L19TNF or L19IL2/L19TNF. Pembrolizumab will be administered by i.v. infusion on the first day of intralesional treatment with ICKs, and will continue every 3 weeks for approximately 2 years, 35 cycles, 2 year cap or until disease progression or unacceptable toxicity, whichever comes first. Follow-up for progression free survival will be performed up to 2 years after first intralesional treatment. Survival information will be collected up to 3 years after first intralesional treatment. A safety run-in will be performed on the first 12 patients enrolled in each arm of the study. Patients will be evaluated during the first 21-days cycle for the occurrence of the treatment-related adverse events. All toxicities will be graded using NCI CTCAE Version 5.0 based on the investigator assessment to be possibly, probably, or definitely related to study treatment administration. In addition to this, safety information collected will be routinely reviewed by the Data and Safety Monitoring Board (DSMB) in order to identify possible safety concerns. The primary objective of the study is to demonstrate the efficacy of intralesional treatment with ICKs, in combination with systemic anti-PD1 immunotherapy with pembrolizumab, to induce objective responses in advanced melanoma patients with resistance to or progressing upon anti-PD1 checkpoint inhibitors. Primary endpoint of the study is the Confirmed Objective Response Rate (ORR = CR + PR) in all three arms over a period of up to 2 years after first intralesional treatment, according to RECIST v1.1 criteria in each arm of the study. The primary analysis will be performed in the Intention-to-Treat population (ITT). For each of the three treatment arms, secondary objectives include efficacy and safety of intralesional treatment with ICKs. The secondary endpoints include: * Best overall response (BOR; the best overall response is the best response recorded from the start of the treatment until disease progression/recurrence according to RECIST v1.1 criteria) * Duration of response (DoR) * Pathological response of one target lesion injected with ICKs at 18 weeks after first treatment * Confirmed ORR over a period of up to 2 years after first intralesional treatment, according to iRECIST (see Appendix 1) and itRECIST \[1\] criteria in each arm of the study * Progression-free survival (PFS) from time of randomization * Overall survival (OS) from randomization * Number, frequency and grading of adverse events (AEs) and serious adverse events (SAEs) related to intralesional therapy with ICKs in combination with systemic anti-PD1 therapy End of treatment: last day of anti-PD1 therapy or until progression or unacceptable toxicity. End of study: corresponds to the last patient last visit (LPLV).
Arms & interventions
- DrugL19IL2
Arm 1: The amount of L19IL2 that is intratumorally administered into injectable cutaneous, subcutaneous, and nodal tumors once weekly for up to 4 weeks is dependent on the size of the tumor. The maximum dose to be administered in a single treatment visit is 13 MioIU/1 mL of L19IL2.
- DrugL19TNF
Arm 2: The amount of L19TNF that is intratumorally administered into injectable cutaneous, subcutaneous, and nodal tumors once weekly for up to 4 weeks is dependent on the size of the tumor. The maximum dose to be administered in a single treatment visit is 400 μg/1 mL of L19TNF.
- DrugL19IL2/L19TNF
Arm 3: The amount of L19IL2/L19TNF that is intratumorally administered into injectable cutaneous, subcutaneous, and nodal tumors once weekly for up to 4 weeks is dependent on the size of the tumor. The maximum dose to be administered in a single treatment visit is 13MioIU L19IL2 + 400 μg L19TNF in a combined total volume of approximate 2 mL. In case that study drug-related, grade ≥ γ AEs are recorded after the first L19IL2/L19TNF dose administration, the L19TNF dose is reduced to 200 μg for the following administrations.
- DrugKEYTRUDA®
KEYTRUDA® will be administered by i.v. infusion as a dose of 200 mg on the first day of intralesional treatment with ICKs and will continue every 3 weeks for approximately 2 years, 35 cycles, 2 year cap or until disease progression or unacceptable toxicity, whichever comes first. ICKs intralesional treatment will be administered 30-60 minutes post administration of KEYTRUDA®.
Outcome measures
Primary
Confirmed Objective Response Rate (ORR)
Objective Response Rate (ORR = CR + PR) in all three arms to demonstrate the efficacy of intralesional treatment with immunocytokines (L19IL2, or L19TNF, or L19IL2/L19TNF), in combination with the systemic anti-PD1 pembrolizumab, to induce objective responses in advanced melanoma patients with resistance to or progressing upon anti-PD1 checkpoint inhibitors. The primary analysis will be performed in the Intention-to-Treat population (ITT). Assessed during Tumor Assessment (TA) visits.
Time frame: Evaluated over a period of up to 2 years after first intralesional treatment. TA visits will be performed at week 12, 18, 24, 36, 48, 64, 80 and 96 after first intralesional treatment or until confirmed progression or death, whichever occurs first
Secondary
Best overall response (BOR)
Time frame: From the date of first treatment until the date of first documented progression or date of death from any cause, whichever comes first, assessed up to 96 Weeks
Duration of Response (DoR)
Time frame: From the date of first treatment until the date of first documented progression or date of death from any cause, whichever comes first, assessed up to 36 Months
Pathological response
Time frame: At 18 weeks after first treatment
Confirmed ORR
Time frame: From date of first administration, after a period of up to 2 years
Progression-free survival (PFS)
Time frame: From the date of randomization until the date of first documented progression or date of death from any cause, whichever comes first, assessed up to 96 Weeks
Overall survival (OS)
Time frame: From the date of randomization until the date of first documented progression or date of death from any cause, whichever comes first, assessed up to 96 Weeks
Serious Adverse Event (SAEs)
Time frame: From date of ICF signature until first follow-up visit (Week 12). Subsequently only AEs and SAEs (and related medications or procedures) that were judged as drug or study related will be recorded, up to week 96
Drug-Induced Liver Injury (DILI)
Time frame: From date of ICF signature until first follow-up visit (Week 12). Subsequently only DILI that were judged as drug or study related will be recorded, up to week 96
Number of patients with Adverse Events of Special Interest (AESI)
Time frame: From date of ICF signature until first follow-up visit (Week 12). Subsequently only AESI that were judged as drug or study related will be recorded, up to week 96
Number of patients with Immune-Related Adverse Events (IRAEs)
Time frame: From date of ICF signature until first follow-up visit (Week 12). Subsequently only IRAEs that were judged as drug or study related will be recorded, up to week 96
Number of participants with abnormal hematology laboratory tests results
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal hematology laboratory tests results
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal hematology laboratory tests results
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal hematology laboratory tests results
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal serum chemistry laboratory tests results
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal serum chemistry laboratory tests results
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal serum chemistry laboratory tests results
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal serum chemistry laboratory tests results
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal serum chemistry laboratory tests results
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal coagulation laboratory tests results
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal body temperature
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal blood pressure
Time frame: From the screening to the last visit (Week 103)
Number of participants with abnormal Electrocardiogram (ECG) readings
Time frame: At the screening visit, at Visit 6 (week 5) and at Visit 12 (week 18)
Number of participants with abnormal Echocardiogram (ECHO) readings
Time frame: At the screening visit, at Visit 6 (week 5) and at Visit 12 (week 18)
Number of participants with abnormal physical examination results
Time frame: From the screening to first follow up visit
Concomitant medication usage
Time frame: From the screening and throughout study
Assessment of the formation of human anti-fusion protein antibodies (HAFA) against L19IL2 and L19TNF
Time frame: At weeks 1, 2 and 12
Eligibility criteria
Study locations (1)
Memorial Sloan Kettering Cancer Center
New York, New York, 10065