Inclusion Criteria:
- - Be willing and able to provide written informed consent for the trial.
- - Have un-resectable (stage III) or advanced (stage IV) melanoma.
- - Be 18 years of age or older on day of signing informed consent.
- - Have measurable disease based on RECIST 1.1.
Patients without measurable disease may
be included on study after discussion with the Sponsor, given that the primary
endpoint of the study is Ki-67 of TIL (flow cytometry)
- - Have biopsiable disease.
Be willing to provide tissue from a newly obtained biopsy
of a tumor lesion. Newly-obtained is defined as a specimen obtained up to 30 days
prior to initiation of treatment on Day 1.
- - Patients may have received prior adjuvant therapy with anti-PD-1, anti-CTLA-4, or
BRAF/MEK inhibitors.
- - Patients may be immunotherapy treatment naïve in the advanced setting or may be on
anti-PD-1 therapy with SD or PR for at least 12 weeks.
Patients may have received
ipilimumab plus nivolumab in the metastatic setting with SD or PR for at least 12
weeks on maintenance anti-PD1.
- - Have a performance status of 0, 1 or 2 on the ECOG Performance Scale.
- - Have a baseline HbA1c ≤ 6.4.
- - Demonstrate adequate organ function.
All screening labs should be performed within
14 days of treatment initiation.
1. Absolute neutrophil count (ANC) ≥1,500 /mcL. 2. Platelets ≥100,000 / mcL. 3. Hemoglobin ≥9 g/dL or ≥5.6 mmol/L without transfusion or EPO dependency (within
7 days of assessment)
4. Serum creatinine OR Measured or calculateda creatinine clearance ≤1.5 X upper
limit of normal (ULN) (GFR can also be used in place of creatinine or CrCl ≥60
mL/min for subject with creatinine levels > 1.5 X institutional ULN)
5. Serum total bilirubin ≤ 1.5 X ULN OR Direct bilirubin ≤ ULN for subjects with
total bilirubin levels > 1.5 ULN. 6. AST (SGOT) and ALT (SGPT) ≤ 2.5 X ULN OR ≤ 5 X ULN for subjects with liver
metastases. 7. Albumin >2.5 mg/dL. 8. International Normalized Ratio (INR) or Prothrombin Time (PT) ≤1.5 X ULN unless
subject is receiving anticoagulant therapy as long as PT or PTT is within
therapeutic range of intended use of anticoagulants; Activated Partial
Thromboplastin Time (aPTT) ≤1.5 X ULN unless subject is receiving anticoagulant
therapy as long as PT or PTT is within therapeutic range of intended use of
anticoagulants.
- - Patients must be free of active brain metastases by contrast-enhanced CT/MRI scans
within 2 weeks prior to starting the study drugs.
If known to have prior brain
metastases, must not have evidence of active (enlarging and/or symptomatic lesions)
brain disease on MRI evaluation within 4 weeks from SRS or WBRT treatment.
- - Patients who have received radiation may be enrolled if the treating physician
determines that they have recovered from radiation and are not experiencing
radiation related clinically significant adverse events.
- - Female patients of child bearing potential must have a negative urine or serum
pregnancy test within 7 days from the time of registration.
- - Female subject of childbearing potential should have a negative urine or serum
pregnancy within 72 hours prior to receiving the first dose of study medication.
If
the urine test is positive or cannot be confirmed as negative, a serum pregnancy
test will be required.
- - Female subjects of childbearing potential should be willing to use 2 methods of
birth control or be surgically sterile, or abstain from heterosexual activity for
the course of the study through 120 days after the last dose of study medication.
Subjects of childbearing potential are those who have not been surgically sterilized
or have not been free from menses for > 1 year.
- - Male subjects should agree to use an adequate method of contraception starting with
the first dose of study therapy through 120 days after the last dose of study
therapy.
Exclusion Criteria:
- - Has a current confirmed diagnosis of type 1 diabetes or type 2 diabetes that has
been diagnosed by an HbA1c ≥6.5, or is on any hypoglycemic medications (insulin,
metformin, etc).
Patients with a screening HbA1c 6.5-7.0 may be included after
discussion with the principal investigator. Patients currently on metformin will be
excluded.
- - Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any
other form of immunosuppressive therapy within 7 days prior to the first dose of
trial treatment.
- - Has a known history of active TB (Bacillus Tuberculosis).
- - Hypersensitivity to pembrolizumab or any of its excipients.
- - Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study
Day 1 (this excludes patients on anti-PD1) or who has not recovered (i.e., ≤ Grade 1
or at baseline) from adverse events due to agents administered more than 4 weeks
earlier.
- - Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy
within 2 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at
baseline) from adverse events due to a previously administered agent.
Note: Subjects
with ≤ Grade 2 neuropathy are an exception to this criterion and may qualify for the
study. If subject received major surgery, they must have recovered adequately from
the toxicity and/or complications from the intervention prior to starting therapy.
- - Has a known additional malignancy that is progressing or requires active treatment.
Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of
the skin that has undergone potentially curative therapy or in situ cervical cancer.
- - Has known active central nervous system (CNS) metastases and/or carcinomatous
meningitis.
Subjects with previously treated brain metastases may participate
provided they are stable (without evidence of progression by imaging for at least
two weeks prior to the first dose of trial treatment and any neurologic symptoms
have returned to baseline), have no evidence of new or enlarging brain metastases,
and are not using steroids for at least 7 days prior to trial treatment. This
exception does not include carcinomatous meningitis which is excluded regardless of
clinical stability.
- - Has active autoimmune disease that has required systemic treatment in the past 2
years (i.e. with use of disease modifying agents, corticosteroids or
immunosuppressive drugs).
Replacement therapy (eg., thyroxineor physiologic
corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is
not considered a form of systemic treatment.
- - Has a history of (non-infectious) pneumonitis that required steroids or current
pneumonitis.
- - Has an active infection requiring systemic IV antibiotic therapy.
- - Has a history or current evidence of any condition, therapy, or laboratory
abnormality that might confound the results of the trial, interfere with the
subject's participation for the full duration of the trial, or is not in the best
interest of the subject to participate, in the opinion of the treating investigator.
- - Has known psychiatric or substance abuse disorders that would interfere with
cooperation with the requirements of the trial.
- - Is pregnant or breastfeeding, or expecting to conceive or father children within the
projected duration of the trial, starting with the pre-screening or screening visit
through 120 days after the last dose of trial treatment.
- - Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies).
- - Has a known history of or is positive for hepatitis B (hepatitis B surface antigen
[HBsAg] reactive) or hepatitis C (hepatitis C virus [HCV] RNA [qualitative] is
detected).
Note: Without known history, testing only needs to be performed if there
is clinical suspicion for Hepatitis B or C.
- - Has received a live vaccine within 30 days of planned start of study therapy.
Note:
Seasonal influenza vaccines for injection are generally inactivated flu vaccines and
are allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live
attenuated vaccines, and are not allowed.
