High Dose Interleukin-2 Followed by Intermittent Low Dose Temozolomide in Patients With Melanoma

Metastatic malignant melanoma remains a disease with a very poor prognosis and median survival duration of less than one year. Durable remissions with conventional therapy are rare and therefore clinical trials remain a primary treatment modality for metastatic disease. There are 2 currently FDA-approved therapies for metastatic melanoma. Chemotherapy with single agent parenteral dacarbazine or its oral pro-drug, temozolomide, are capable of producing responses in 6.5 to 20% of patients. These responses are usually minor to partial at best and are not durable. Combination with other chemotherapeutic drugs has not been successful. The immune system also seems to play a role in malignant melanoma. High dose Interferon therapy is the current standard therapy for the adjuvant treatment of stage IIB, IIC and III melanoma after surgical resection in which it has shown to result in modest improvements in disease free survival and overall survival. In metastatic disease, various immunologic approaches have been employed as well. High dose IL-2 can produce a response rate of about 10-15% in patients with metastatic melanoma. About 5-10% of responses are complete and some of these complete responses are durable so that the lucky few patients who have a durable complete response are for all intents and purposes cured. Attempts to combine chemotherapy with immunotherapy, although improving response rates, has not impacted survival as summarized in recent meta-analysis.

Inclusion criteria

• Pathologically confirmed metastatic malignant melanoma
• Age > 18 years
• Eastern Cooperative Oncology Group performance status of 0 or 1
• Patients considered good candidate for conventional high dose IL-2
• No chemotherapy, hormonal therapy, immunotherapy or radiation therapy within 1 month of entry
• Patients with a history or clinical evidence of brain metastasis must have completed radiation therapy or surgical treatment of brain lesions and have no evidence of central nervous system progression for at least 8 weeks at the time of enrollment.
• Patients may have had prior high dose IL-2 or temozolomide but not together or with high dose IL-2 followed by temozolomide
• Patients may have had prior high dose interferon as adjuvant treatment for high risk melanoma
• Serum creatinine < 2 mg/dL
• Bilirubin < 2 mg/dL

Exclusion criteria

• Inability to provide informed consent
• Hypersensitivity to temozolomide or HD IL-2
• Active gastrointestinal disorder or cardiac disorders
• Ejection fraction < 50% by echocardiogram or corrected diffusing capacity of lung for carbon monoxide < 50% on diffusion capacity testing pulmonary function tests
• platelets < 100 K, neutrophils < 1000
• Serum Creatinine < 2 x the upper limits of normal
• Chronic use of steroids other than for simple adrenal replacement