Download subject inclusion criteria - Istituto Superiore di Sanità

ISS-DPII
18/02/2009
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STUDY PROTOCOL
Title
Peptide-based vaccine in combination with chemotherapy in
melanoma patients: a phase II randomized clinical study.
Study code
ISS-DPII
Study phase
II
Sponsor
Istituto Superiore di Sanità
Study Chairman
Prof. Enrico Garaci
Istituto Superiore di Sanità - Rome, Italy
Study Coordinators
Dr. Filippo Belardelli
Istituto Superiore di Sanità - Rome, Italy
Prof. Francesco Cognetti
IFO-Istituto Regina Elena - Rome, Italy
Dr. Paola Nisticò
IFO-Istituto Regina Elena - Rome, Italy
Dr. Enrico Proietti
Istituto Superiore di Sanità - Rome, Italy
Principal Investigator
Dr. Virginia Ferraresi
IFO-Istituto Regina Elena - Rome, Italy
Co-Investigator
Dr. Caterina Catricalà
IFO-Istituto S. Gallicano – Rome, Italy
Writing Committee
Dr. Enrico Proietti - ISS, Rome
Dr. Paola Nisticò - IFO, Rome
Dr. Imerio Capone - ISS, Rome
Dr. Virginia Ferraresi - IFO, Rome
Dr. Patrizio Pezzotti - ASP Lazio, Rome
Dr. Diana Giannarelli - IFO, Rome
Date
18/02/2009
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18/02/2009
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PROTOCOL SUMMARY
TITLE
Peptide-based vaccine in combination with chemotherapy in melanoma patients: a phase II
randomized clinical study.
PHASE
Randomized, open, phase II study.
INVESTIGATIONAL DRUGS
Dacarbazine (Deticene; Sanofi-Aventis, Fr)
IFN-2b (IntronA®), Roche, Ch)
Melan-A/MART-126-35(27L) e NY-ESO-1157-165 (NeoMPS, Fr)
Montanide ISA-51 (Seppic, Fr)
STUDY DESIGN
This is a phase II, open-label, randomized study which evaluate in stage III and IV (with
resected tumor) melanoma patients, a vaccination treatment versus a combined chemo-vaccine
treatment. At least 50 subjects (25/arm) will be enrolled to receive the two treatments. Subjects will
be asked to sign an informed consent form before entering the study.
Patients will be assigned to two treatment arms. Patients in arm I will receive i.d. injections
of Melan-A/MART-1 and NY-ESO 1 peptides (250 μg each), formulated in Montanide ISA-51, plus
s.c. injection of 6 MU interferon-α (IFN-α) as an immune adjuvant. The treatment includes 6
administration courses, each course repeated every 21 days and comprising two vaccine/IFN
injections on days 1 and 8. Patients in arm II will receive the same
vaccination schedule combined with DTIC (800 mg/mq i.v.) administered one day before each
vaccination course (i.e every 21 days).
Before treatment and after the 4thand 6th treatment course as well as at 6 th month from the
beginning of the treatment blood samples will be taken for determining safety as well as efficacy
parameters. Additional small blood samples will be taken after each remaining treatment course for
determining only specific safety parameters and T-cell response (as illustrated in appendix 1).
During treatment, patient clinical status will be monitored at each visit and any disease
recurrence will be checked by appropriate diagnostic investigations at specific time points. After the
end of the treatment, a two years follow-up period is foreseen. Patients showing any relapse during
the treatment period will be withdrawn from the study and will not be considered assessable.
We estimate 24 months to reach 50 subjects who will be assessable for primary as well as
secondary endpoints. The expected duration of the study is 4 years.
STUDY POPULATION
Stage IIIb (with macrometastases, any Nb-c) and IIIc or IV M1a or M1b, according to the
AJCC classification, disease-free melanoma patients will be enrolled in the study. Patients whithout
evidence of disease, as documented by CT scan performed within 30 days before randomization,
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will be enrolled. Selection of the study population will be carried out at the following centers: Regina
Elena Cancer Institute and S. Gallicano Dermatological Institute.
SUBJECT INCLUSION CRITERIA
•
Histologically confirmed AJCC stage IIIb or IIIc or IV (M1a or M1b) disease-free HLAA*0201melanoma;
•
Adult subjects of 18 years of age;
•
ECOG score 0-1;
•
Life expectancy of at least 6 months;
•
Hematopoietic, liver and renal normal functions defined as follows: WBC  3 x 103/μl;
platelets  100 x 103/μl; Hb 10 g/dl; absolute neutrophil count  1,5 x 103/μl; bilirubin ≤ 2.0
mg/dl; AST, ALT and LDH less than 3 times upper limit of normal; serum creatinine ≤ 2 mg
/dl;
•
Fertile females have to practice adequate contraception;
•
Signed informed consent;
SUBJECT EXCLUSION CRITERIA
•
Current other malignancy at other sites or previous other cancer within the last 5 years, with
the exception of adequately treated con-biopsied in situ carcinoma of the cervix uteri or
basal or squamous cell carcinoma of the skin;
•
Concurrent chemotherapy or immunotherapy;
•
Prior chemotherapy, immunotherapy or radiotherapy, unless ended at least 4, 4 and 4
weeks, respectively before admission to the present study;
•
Significant cardiovascular diseases requiring medical intervention or prior myocardial
infarction within the last 2 years;
•
Primary or secondary immunodeficiency, including immunosuppressive disease, or use of
immunosuppressive medications;
•
Active or chronic infection (including HIV, HBV, HCV)
•
Women must not be pregnant or breast-feeding;
•
Simultaneous participation in another clinical trial, or participation in any clinical trial
involving investigational drugs within 3 months from enrolment into the present study;
•
Any physical or psychological impediment in a patient that could let the
investigator to suspect his/her poor compliance
TREATMENT
Group I (25 Pts). Peptide vaccine [250 g of MART 1:26 35(27L) + 250 g of NY-ESO-1:157-165
formulated in Montanide ISA-51] in association with 6 MU of IFN-2b. The immunization regimen
consists 6 cycles of two vaccination each, for a total of 12 injections of peptide vaccine,
administered in combination with IFN-2b.
Group II (25 Pts). Peptide vaccine, as in group 1, associated with dacarbazine (800mg/m2)
administered every 21 days, 1 day before each vaccination cycle, for a total of 6 injections.
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OBJECTIVES
The main objective of this study is to evaluate the efficacy of a combined chemo-vaccine
therapy in increasing the distant metastases-free survival of disease-free melanoma patients.
Primary endpoint.
Distant metastases-free survival (DMFS). Primary endpoint of the study is to determine
whether DTIC plus vaccine administration could prevent distant relapse and death of patients with
high-risk resected melanoma. DMFS is defined as the length of time from randomization to the first
distant recurrence of melanoma. Patients will be monitored during study and site and interval of
relapses were recorded. Treatment comparisons for DMFS will be conducted using a stratified logrank test. The Kaplan±Meier method will be used to calculate plots of estimated relapse-free
survival. Cox's proportional hazards regression will be used to assess the impact of treatment after
adjustment for other patient characteristics.
Secondary endpoints
Magnitude and quality of the immune responses of treated patients and their correlations
with clinical responses will be determined. The following immune parameters will be characterized.
i) DTH. DTH test, by using vaccine peptides as antigens, will be performed as clinical
measure of vaccine-induced immune response.
ii) CTL response. The magnitude of the response will be determined by enumerating
vaccine-specific CD8+ T cells in the peripheral blood. This will be carried out by
ELISPOT as well as by tetramer staining assays. The quality of the response will by
determined by measuring the lytic activity of CD8 + T cells, by standard 51Cr-release
assay.
Additional secondary end-points, determined only in patients who will give their
consent, will be the followings.
iii) Cytokine multiparametric analysis. The functional characterisation of vaccine-specific
CD8+ T cells will be determined through the analysis of the production of a panel of
cytokines measured by intracellular staining technique will be determined, and the
correlatation of these parameters with other immune as well as clinical responses will
be evaluated.
iv) Gene expression profiles. Microarray analysis will be also performed on RNA isolated
from patients PBMCs before and one day after DTIC administration at selected time
points, in order to possibly identify genes involved in DTIC-dependent activation of
immune responses.
v) Functional study on NKG2D ligands expression. The function of NKG2D receptor in the
lysis of tumour cells by NK and CD8+ T cells of tumour patients will be studied by Cr51release assay in the presence of neutralizing anti-NKG2D antibodies. By ELISA assay,
we will measure the levels of soluble NKG2D ligands (MICA, MICB and ULBP1-4) in
the serum of tumour patients. The in vivo expression will be evaluated by FACS
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staining and immunohistochemistry methods in primary as well as metastatic
melanoma.
Safety and tolerability and OS. Additional secondary endpoints are the evaluation of safety
and tolerability of the treatment, by evaluating frequency, type and intensity of adverse events
(according to CTC classification, see section 9.3.3 for events not listed in the CTC classification)
and OS of the patients.
STATISTICAL CONSIDERATION
Primary endpoints.
Efficacy
The primary endpoint of the study is to determine whether DTIC plus vaccine administration could
prevent relapse and death of patients with high-risk resected melanoma, thus increasing their
DMFS. Patients will be monitored during study and site and interval of relapses will be recorded.
The Kaplan±Meier method will be used to calculate plots of estimated distant relapse-free survival.
Cox's proportional hazards regression will be used to assess the impact of treatment after
adjustment for other patient characteristics.
Secondary endpoints
The secondary endpoint of the study is to determine the magnitude and quality of the immune
responses of treated patients and their correlations with clinical responses. Safety and tolerability
of the treatment as well as OS are additional secondary endpoint.
The following immune parameters will be characterized.
DTH. DTH test, by using vaccine peptides as antigens, will be performed as clinical measure of
vaccine-induced immune response.
CTL response. The magnitude of the response will be determined by enumerating vaccine-specific
CD8+ T cells in the peripheral blood. This will be carried out by ELISPOT as well as tetramer
staining assays. The functional properties of CD8+ T cells will by determined by measuring the lytic
activity by standard 51Cr-release assay.
Cytokine multiparametric analysis. An additional functional characterisation of vaccine-specific
CD8+ T cells will be obtained through the analysis of the production of a panel of cytokines
measured by intracellular staining technique will be performed, and the correlation of these
parameters with other immune as well as clinical responses will be evaluated.
Gene expression profiles. Microarray analysis will be also performed on PBMCs before and one
day after DTIC administration at selected time points, in order to possibly identify genes involved in
DTIC-dependent activation of immune responses.
Functional study on NKG2D ligands expression. The function of NKG2D receptor in the lysis of
tumour cells by NK and CD8+ T cells of tumour patients will be studied by Cr51-release assay in the
presence of neutralizing anti-NKG2D antibodies. By ELISA assay, we will measure the levels of
soluble NKG2D ligands (MICA, MICB and ULBP1-4) in the serum of tumour patients. The tumor
tissue expression will be evaluated by immunohistochemistry methods in primary as well as
metastatic melanoma.
Safety
Frequency, type and intensity of adverse events as well as clinically relevant changes in the
laboratory parameters will be will be monitored to evaluate safety and tolerability of the treatment.
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CLINICAL SITES
Regina Elena Cancer Institute, Rome, Italy
S. Gallicano Dermatological institute, Rome, Italy
STUDY DURATION
4 years
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