Phase II Trial of Combination Anti-PD-1 and Aldesleukin for Metastatic Melanoma and Renal Cell Carcinoma

Background:

High-dose interleukin-2 was approved by the FDA for the treatment of metastatic melanoma and renal cell carcinoma, with overall response rates of 15-16%. Complete regression of disease was seen in 6-7% of participants with many long-term durable responses. The regimen has not been widely adopted due to complexities in management and the development of alternative effective therapies, such as monoclonal antibodies targeting immune checkpoints (ipilimumab, pembrolizumab, nivolumab) or small molecule inhibitors.

Pembrolizumab was approved by the FDA for the treatment of metastatic melanoma based on a series of studies demonstrating objective response rates from 21-34%. There remains a considerable population of participants with disease that never responded to treatment, in addition to participants with short durations of response prior to recurrence.

There has been limited clinical investigation of the combination of interleukin-2 and pembrolizumab. The hypothesis under investigation is that non-specific activation of the immune system with both positive stimulation (aldesleukin) and release of negative regulation (pembrolizumab) may have meaningful clinical impact for participants with limited therapeutic options.

Objectives:

Primary:

To determine the objective response rate as determined by RECIST 1.1 criteria to combined aldesleukin and pembrolizumab in participants with advanced melanoma refractory to anti-PD-1 therapy and treatment-refractory metastatic renal cell carcinoma

Secondary:

To determine progression free survival with the combined regimen

To determine the toxicity profile of this treatment regimen

To determine the objective response rate as determined by RECIST 1.1 criteria to combined aldesleukin and pembrolizumab in participants with treatment-na(SqrRoot) ve advanced melanoma

Exploratory:

To evaluate clinical and laboratory correlates of response

To perform immunologic correlative studies of peripheral blood, tumor, and/or tumor infiltrating lymphocytes including but not limited to phenotype and functional analysis of longitudinal samples

Eligibility:

Participants must be/have:

Age >= 18 years of age.

ECOG performance status of 0 or 1.

Expected survival of greater than 6 months.

Histologically or cytologically confirmed melanoma or renal cell cancer, as follows:

Cohort 1: Metastatic melanoma or advanced locoregional melanoma not amenable to curative surgical resection and refractory to anti-PD-1 therapy.

Cohort 2: Metastatic renal cell carcinoma (clear cell histology) refractory to at least one line of PD1/PDL1 based therapy.

Cohort 3: Metastatic or advanced locoregional melanoma not amenable to curative surgical resection na(SqrRoot) ve to anti-PD-1 therapy.

No allergies or hypersensitivity to high-dose aldesleukin or pembrolizumab administration.

No concurrent major medical illnesses or any form of immunodeficiency.

No history of Grade 3/4 immune-related adverse events affecting major organ systems associated with the administration of single agent pembrolizumab or nivolumab.

Design:

Study treatment will be given in two courses. A course shall consist of two cycles (each 21 days) of treatment. Cycles in Course 1 shall consist of pembrolizumab (200 mg IV) infusion on the morning of Day 1 with aldesleukin (IL-2) administration (600,000 IU/kg intravenous bolus every eight hours) to begin later that day. IL-2 will be administered to tolerance or to a maximum of 10 doses.

A second cycle of treatment will begin during Week 4 (Day 22-28).

Approximately two months from the beginning of therapy, participants will be evaluated for response including physical exam, clinical laboratory testing, and cross-sectional imaging.

Participants that do not demonstrate progressive disease will receive a second course of pembrolizumab alone, if clinically appropriate.

Participants with stable disease will be monitored until disease progression (every 3 months x 3) up to one year.

Participants with an objective response will be monitored until disease progression (every 3 months x 3, every 6 months x 8) up to five years.

• INCLUSION CRITERIA:
• Participants must have histologically or cytologically confirmed cancer that falls into one of three cohorts: (1) metastatic melanoma or advanced locoregional melanoma not amenable to curative surgical resection and refractory to anti-PD-1 therapy; (2) metastatic renal cell carcinoma (clear cell histology) refractory to at least one line of PD1/PDL1 based therapy; (3) metastatic or advanced locoregional melanoma not amenable to curative surgical resection and naive to anti-PD-1 therapy.
• Participants must have measurable disease (per RECIST v1.1 criteria), metastatic melanoma or renal cell cancer.
• Age >=18 years of age.
• Clinical performance status of ECOG 0 or 1.
• Willing to practice birth control from the time of enrollment on this study and for four months after treatment.
• Must have a negative pregnancy test because of the potentially dangerous effects of the treatment on the fetus.
• Seronegative for HIV antibody. (The experimental treatment being evaluated in this protocol depends on an intact immune system. Participants who are HIV seropositive may have decreased immune-competence and thus be less responsive to the experimental treatment and more susceptible to its toxicities.)
• Seronegative for hepatitis B antigen and for hepatitis C antibody. If hepatitis C antibody test is positive, then participant must be tested for the presence of antigen by RT-PCR and be HCV RNA negative.
• Participants must have adequate organ and marrow function as defined below:

• ANC > 1000/mm^3 without the support of filgrastim
• WBC >= 3000/mm^3
• Platelet count >= 100,000/mm^3
• Hemoglobin > 8.0 g/d (Subject may be transfused to reach this cut-off)
• Serum ALT/AST <= 5.0 x ULN
• Serum creatinine <= 1.6 mg/dL
• Total bilirubin <= 2.0 mg/dL, except in participants with Gilbert s Syndrome, who must have a total bilirubin < 3.0 mg/dL.
• More than four weeks must have elapsed since completion of any prior systemic therapy at the time of enrollment.

Note: Participant may have undergone minor surgical procedures or limited field radiotherapy within the four weeks prior to enrollment, as long as related major organ toxicities have recovered to <= grade 1.

• Ability of subject to understand and the willingness to sign a written informed consent document.
• Willing to sign a Durable Power of Attorney Form.
• Subject must be co-enrolled on protocol 03-C-0277

Exclusion criteria

• Participant is nursing because of the potentially dangerous effects of the treatment on the fetus or infant.
• Concurrent systemic steroid therapy.
• Active systemic infections requiring anti-infective treatment, coagulation disorders, or any other active or uncompensated major medical illnesses.
• Any form of primary immunodeficiency (such as Severe Combined Immunodeficiency Disease and AIDS).
• History of major organ autoimmune disease.
• Grade 3 or 4 major organ irAEs following treatment with anti-PD-1/PD-L1 monotherapy, including but not limited to myocarditis, pneumonitis, colitis, and hepatotoxicity.
• Concurrent opportunistic infections (The experimental treatment being evaluated in this protocol depends on an intact immune system. Participants who have decreased immune-competence may be less responsive to the experimental treatment and more susceptible to its toxicities.)
• History of severe immediate hypersensitivity reaction to pembrolizumab or aldesleukin.
• History of coronary revascularization or ischemic symptoms.
• For select participants with a clinical history prompting cardiac evaluation: last known LVEF <= 45%.
• For select participants with a clinical history prompting pulmonary evaluation: known FEV1 <= 50%.
• Participant is receiving any other investigational agents.