A Study to Compare the Administration of Pembrolizumab After Surgery Versus Administration Both Before and After Surgery for High-Risk Melanoma

Purpose

This phase II trial studies how pembrolizumab works before and after surgery in treating patients with stage III-IV high-risk melanoma. Immunotherapy with monoclonal antibodies, such as pembrolizumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Giving pembrolizumab before and after surgery may work better compared to after surgery alone in treating melanoma.

Conditions

  • Acral Lentiginous Melanoma
  • Clinical Stage III Cutaneous Melanoma AJCC v8
  • Clinical Stage IV Cutaneous Melanoma AJCC v8
  • Mucosal Melanoma

Eligibility

Eligible Ages
Over 18 Years
Eligible Genders
All
Accepts Healthy Volunteers
No

Criteria


Inclusion Criteria:

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must have clinically detectable stage
III (clinically detectable N1b, N1c, N2b, N2c, N3b and N3c) or stage IV resectable
melanoma. Patients with melanoma of mucosal or acral origin are eligible. Patients
with melanoma of uveal origin are not eligible. Patients with a history of brain
metastases are not eligible. Clinically detectable is defined as disease that is
apparent and measurable via physical examination or radiographic imaging.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients are eligible for this trial either at
initial presentation of their melanoma or at the time of the first detected nodal,
satellite/in-transit, distant metastases, or recurrent disease in prior
lymphadenectomy basin or distant site. Nodal, satellite/in-transit metastasis, distant
metastases or disease in a prior complete lymphadenectomy basin must have been
confirmed histologically by hematoxylin (H) & eosin (E) stained slides.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients with multiple regional nodal basin
involvement are eligible. Gross or microscopic extracapsular nodal extension is
permitted.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must have histologically proven stage
IIIB or higher. This would entail pathologic confirmation beyond the primary or
initial diagnosis of melanoma involving fine needle aspiration cytology or biopsy
confirmation of any N-category or M-category resectable site.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must not have received previous
neoadjuvant treatment for their melanoma. Patients may have received prior
non-immunotherapy adjuvant therapy. Patients must not have had prior immunotherapy
including, but not limited to ipilimumab, interferon alfa-2b, high dose interleukin
(IL)-2, pegylated-interferon (PEG-IFN), anti-PD-1, anti-PD-L1 intra-tumoral, or
vaccine therapies. Patients must not be planning to receive any of the prohibited
therapies during treatment phases on the study.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must not be planning to receive
concomitant other biologic therapy, hormonal therapy, other chemotherapy, surgery,
while on protocol therapy.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients may have received prior radiation
therapy, including after prior surgical resection. All adverse events associated with
prior surgery and radiation therapy must have resolved to =< grade 1 prior to
randomization.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must be >= 18 years of age

- STEP 1 REGISTRATION (RANDOMIZATION): All patients must have disease status documented
by a complete physical examination and imaging studies within 42 days prior to
randomization. Imaging studies must include a CT of the chest, abdomen and pelvis with
intravenous contrast (unless contraindicated). For patients with melanoma arising from
the head and neck, dedicated neck imaging (CT with intravenous contrast is required.
If the patient has unknown primary with disease in the axilla, neck imaging is
required CT imaging must be done with intravenous contrast if there are no
contraindications for it. Extremity melanomas must be imaged using CT with intravenous
contrast or MRI with and without gadolinium

- Note: PET-CT scans are NOT acceptable to establish eligibility. Non-iodinated CT
scans that are part of common PET-CT imaging protocols do not provide contrast
for difficult to ascertain areas such as the neck and liver, and do not provide
enough CT detail to perform appropriate RECIST 1.1 measurements. As such, a
PET-CT with non-contrast CT or non-diagnostic quality CT images is considered
insufficient for the detection of melanoma.

- STEP 1 REGISTRATION (RANDOMIZATION): All patients must have a CT or magnetic resonance
imaging (MRI) of the brain within 42 days prior to randomization. The brain CT or MRI
should be performed with intravenous contrast (unless contraindicated).

- STEP 1 REGISTRATION (RANDOMIZATION): Absolute neutrophil count (ANC) >=
1,500/microliter (mcL) (within 42 days prior to randomization).

- STEP 1 REGISTRATION (RANDOMIZATION): Platelets >= 100,000/mcL (within 42 days prior to
randomization).

- STEP 1 REGISTRATION (RANDOMIZATION): Hemoglobin >= 10 g/dL (within 42 days prior to
randomization).

- STEP 1 REGISTRATION (RANDOMIZATION): Total bilirubin =< 1.5 x institutional upper
limit of normal (IULN) (except patients with Gilbert's syndrome, who must have a total
bilirubin < 3.0 mg/dL) (within 42 days prior to randomization).

- STEP 1 REGISTRATION (RANDOMIZATION): Serum glutamic-oxaloacetic transaminase (SGOT)
(aspartate aminotransferase [AST]) and serum glutamate pyruvate transaminase (SGPT)
(alanine aminotransferase [ALT]) =< 2 x IULN (within 42 days prior to randomization).

- STEP 1 REGISTRATION (RANDOMIZATION): Alkaline phosphatase =< 2 x IULN (within 42 days
prior to randomization).

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must have lactate dehydrogenase (LDH)
performed within 42 days prior to randomization.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must have adequate renal function as
evidenced by calculated creatinine clearance > 30 mL/min. The creatinine level (mg/dL)
used in the calculation must be obtained within 42 days prior to randomization.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must have Zubrod performance status =<
2.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must not have a history of
(non-infectious) pneumonitis that required steroids or current pneumonitis.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must not have an active infection
requiring systemic therapy.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must not have active autoimmune disease
that has required systemic treatment in past 2 years (i.e., with use of disease
modifying agents, corticosteroids or immunosuppressive drugs). Replacement therapy
(e.g., thyroxine, insulin, or physiologic corticosteroid replacement therapy for
adrenal or pituitary insufficiency, etc.) is not considered a form of systemic
treatment.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must not have received live vaccines
within 42 days prior to randomization. Examples of live vaccines include, but are not
limited to, the following: measles, mumps, rubella, chicken pox, shingles, yellow
fever, rabies, Bacillus Calmette-Guerin (BCG), and typhoid (oral) vaccine. Seasonal
influenza vaccines for injection are generally killed virus vaccines and are allowed;
however, intranasal influenza vaccines (e.g., Flu-Mist) are live attenuated vaccines,
and are not allowed.

- NOTE: The COVID-19 vaccines (currently available and those in the pipeline for
FDA emergency use authorization or FDA approval) do not contain live virus, and
therefore, COVID-19 vaccination does not affect or preclude eligibility for the
S1801 trial. For patients who have undergone lymphadenectomy, vaccines should be
delivered to a limb with an intact lymph node basin (Sentinel lymph node biopsy
in a limb is acceptable). The vaccine should not be administered in a limb that
has undergone lymphadenectomy.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients known to be human immunodeficiency virus
(HIV) positive are eligible if they meet the following criteria within 30 days prior
to randomization: stable and adequate CD4 counts (>= 350 mm^3), and serum HIV viral
load of < 25,000 IU/ml. Patients may be on or off anti-viral therapy so long as they
meet the CD4 count criteria.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must not have known active hepatitis B
virus (HBV) or hepatitis C virus (HCV) infection prior to randomization. Note: No
testing for hepatitis B and hepatitis C is required unless mandated by local health
authority.

- STEP 1 REGISTRATION (RANDOMIZATION): Prior malignancy is allowed providing it does not
require concurrent therapy.

- STEP 1 REGISTRATION (RANDOMIZATION): Women of childbearing potential must have a
negative urine or serum pregnancy test within 28 days prior to randomization.
Women/men of reproductive potential must have agreed to use an effective contraceptive
method for the course of the study through 120 days after the last dose of study
medication. Should a woman become pregnant or suspect she is pregnant while she or her
partner is participating in this study, she should inform her treating physician
immediately. A woman is considered to be of "reproductive potential" if she has had
menses at any time in the preceding 12 consecutive months. In addition to routine
contraceptive methods, "effective contraception" also includes heterosexual celibacy
and surgery intended to prevent pregnancy (or with a side-effect of pregnancy
prevention) defined as a hysterectomy, bilateral oophorectomy, or bilateral tubal
ligation. However, if at any point a previously celibate patient chooses to become
heterosexually active during the time period for use of contraceptive measures
outlined in the protocol, he/she is responsible for beginning contraceptive measures.
Patients must not be pregnant or nursing due to unknown teratogenic side effects.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must be deemed medically fit to undergo
surgery by the treating medical/surgical team.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must be willing to submit the following
surgical specimens: either all tissue blocks from the surgical specimen or two slides
per block ([1] hematoxylin and eosin [H&E] slide and [1] unstained slide OR [2]
unstained slides if H&E stained slides cannot be provided).

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must be offered the opportunity to
participate in specimen banking.

- STEP 1 REGISTRATION (RANDOMIZATION): Patients must be informed of the investigational
nature of this study and must sign and give written informed consent for this protocol
in accordance with institutional and federal guidelines.

- STEP 1 REGISTRATION (RANDOMIZATION): As a part of the Oncology Patient Enrollment
Network (OPEN) randomization process the treating institution's identity is provided
in order to ensure that the current (within 365 days) date of institutional review
board approval for this study has been entered in the system.

- STEP 2 REGISTRATION (SURGERY): Patients randomized to arm 2 (neoadjuvant arm) must be
willing to submit tissue to determine pathologic response regardless of number of
pre-operative doses of pembrolizumab (MK-3475) received. Determination of pathologic
response cannot be done on less than the full surgical specimen.

- STEP 2 REGISTRATION (SURGERY): Patients must have disease assessments by CT
chest/abdomen/pelvis with IV contrast, and neck CT with IV contrast if primary head
and neck melanoma, performed within 42 days (and no more than 49 days) before the
planned date of surgery. MRI combined with non-contrast CT is an acceptable
alternative for patients with CT contrast allergy, but imaging must encompass total
body.

- STEP 2 REGISTRATION (SURGERY): Patients must register to step 2 within 17 days prior
to planned date of surgery.

- STEP 3 REGISTRATION (ADJUVANT THERAPY): Patients must have undergone surgery prior to
Step 3 registration. The Step 2 surgery must have completely resected their melanoma.

- Patients with gross positive residual disease following surgery do not qualify as
having disease-free status, and, therefore, such patients are not eligible to
register for adjuvant therapy.

- Patients with microscopic residual disease (i.e., positive margins) can be
treated with re-excision or radiation, per site discretion, to render the patient
disease-free prior to registration of adjuvant therapy.

- Disease-free status must be documented by a complete physical examination and
radiographic imaging studies within 42 days prior to Step 3 registration. Imaging
studies must include a CT of the chest, abdomen, and pelvis (unless
contraindicated). Extremity melanomas must be imaged using CT with intravenous
contrast or MRI with and without gadolinium. CT imaging must be done with
intravenous contrast if there are no contraindications for it.

- For patients with melanoma arising from the head and neck, dedicated neck imaging
(CT with IV contrast, unless contraindicated) is required.

- If the patient has had unknown primary with disease in the axilla, neck imaging
is required to assure the region is clear of cancer.

- Any other clinically indicated imaging studies if performed (e.g., bone scan)
must show no evidence of disease.

- STEP 3 REGISTRATION (ADJUVANT THERAPY): Patients must be registered to step 3 no more
than 84 days after date of surgery.

- STEP 3 REGISTRATION (ADJUVANT THERAPY): Patients with R0 or R1 resections must have
disease-free status documented by a complete physical examination and imaging studies
within 42 days prior to step 3 registration. These patients must have disease
assessments by CT chest/abdomen/pelvis with IV contrast, and neck CT with IV contrast
if primary head and neck melanoma. MRI combined with non-contrast CT is an acceptable
alternative for patients with CT contrast allergy, but imaging must encompass total
body.

- STEP 3 REGISTRATION (ADJUVANT THERAPY): Patients with R2 resections are not eligible
for step 3 and must be removed from study treatment

Study Design

Phase
Phase 2
Study Type
Interventional
Allocation
Randomized
Intervention Model
Parallel Assignment
Primary Purpose
Treatment
Masking
None (Open Label)

Arm Groups

ArmDescriptionAssigned Intervention
Experimental
Arm I (adjuvant pembrolizumab)
Within 17 days (preferably within 14 days) days after IV over 30 minutes on day 1. Treatment repeats every 3 weeks for 18 cycles in the absence of disease progression or unacceptable toxicity. Patients also undergo collection of blood throughout the study and MRI or CT on study.
  • Procedure: Biospecimen Collection
    Undergo collection of blood
    Other names:
    • Biological Sample Collection
    • Biospecimen Collected
    • Specimen Collection
  • Procedure: Computed Tomography
    Undergo CT
    Other names:
    • CAT
    • CAT Scan
    • Computed Axial Tomography
    • Computerized Axial Tomography
    • Computerized axial tomography (procedure)
    • Computerized Tomography
    • CT
    • CT Scan
    • tomography
  • Procedure: Magnetic Resonance Imaging
    Undergo MRI
    Other names:
    • Magnetic Resonance
    • Magnetic resonance imaging (procedure)
    • Magnetic Resonance Imaging Scan
    • Medical Imaging, Magnetic Resonance / Nuclear Magnetic Resonance
    • MR
    • MR Imaging
    • MRI
    • MRI Scan
    • MRIs
    • NMR Imaging
    • NMRI
    • Nuclear Magnetic Resonance Imaging
    • sMRI
    • Structural MRI
  • Biological: Pembrolizumab
    Given IV
    Other names:
    • BCD-201
    • Keytruda
    • Lambrolizumab
    • MK-3475
    • Pembrolizumab Biosimilar BCD-201
    • SCH 900475
  • Procedure: Therapeutic Conventional Surgery
    Undergo surgery
Active Comparator
Arm II (adjuvant and neoadjuvant pembrolizumab)
Patients receive pembrolizumab IV over 30 minutes on day 1 every 3 weeks for 3 cycles, then undergo surgery within 3 weeks. Within 84 days, patients receive pembrolizumab IV over 30 minutes every 3 weeks for 15 cycles in the absence of disease progression or unacceptable toxicity. Patients also undergo collection of blood throughout the study and MRI or CT on study.
  • Procedure: Biospecimen Collection
    Undergo collection of blood
    Other names:
    • Biological Sample Collection
    • Biospecimen Collected
    • Specimen Collection
  • Procedure: Computed Tomography
    Undergo CT
    Other names:
    • CAT
    • CAT Scan
    • Computed Axial Tomography
    • Computerized Axial Tomography
    • Computerized axial tomography (procedure)
    • Computerized Tomography
    • CT
    • CT Scan
    • tomography
  • Procedure: Magnetic Resonance Imaging
    Undergo MRI
    Other names:
    • Magnetic Resonance
    • Magnetic resonance imaging (procedure)
    • Magnetic Resonance Imaging Scan
    • Medical Imaging, Magnetic Resonance / Nuclear Magnetic Resonance
    • MR
    • MR Imaging
    • MRI
    • MRI Scan
    • MRIs
    • NMR Imaging
    • NMRI
    • Nuclear Magnetic Resonance Imaging
    • sMRI
    • Structural MRI
  • Biological: Pembrolizumab
    Given IV
    Other names:
    • BCD-201
    • Keytruda
    • Lambrolizumab
    • MK-3475
    • Pembrolizumab Biosimilar BCD-201
    • SCH 900475
  • Procedure: Therapeutic Conventional Surgery
    Undergo surgery

More Details

Status
Active, not recruiting
Sponsor
National Cancer Institute (NCI)

Study Contact

Detailed Description

PRIMARY OBJECTIVE: I. To compare event-free survival (EFS) in participants with high-risk resectable melanoma randomized to neoadjuvant pembrolizumab (MK-3475) with participants randomized to adjuvant pembrolizumab (MK-3475). SECONDARY OBJECTIVES: I. To assess the frequency and severity of toxicities on each of the arms. II. To compare between arms overall survival (OS), disease control at 24 weeks, locoregional control in the surgical site(s), and total number of pembrolizumab (MK-3475) doses received. III. On the neoadjuvant arm, to estimate the pathologic response rate, the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 response rate (confirmed and unconfirmed complete response [CR] and partial response [PR]), and the immune-related (i)RECIST response rate (confirmed and unconfirmed CR and PR), before surgical resection; to compare definitions of pathologic partial response; and to evaluate the association between pathologic response and EFS and OS. IV. To describe the proportion of participants on each arm who received the surgery planned at randomization. ADDITIONAL OBJECTIVE: I. To bank tumor tissue and whole blood in anticipation of future correlative studies in this participant population. OUTLINE: Patients are randomized to 1 of 2 arms. ARM I: Within 17 days (preferably within 14 days) days after surgical resection, patients receive pembrolizumab intravenously (IV) over 30 minutes on day 1. Treatment repeats every 3 weeks for 18 cycles in the absence of disease progression or unacceptable toxicity. Patients also undergo collection of blood throughout the study, and magnetic resonance imaging (MRI) or computers tomography (CT) on study. ARM II: Patients receive pembrolizumab IV over 30 minutes on day 1 every 3 weeks for 3 cycles, then undergo surgical resection within 3 weeks. Within 84 days, patients receive pembrolizumab IV over 30 minutes every 3 weeks for 15 cycles in the absence of disease progression or unacceptable toxicity. Patients also undergo collection of blood throughout the study and MRI or CT on study. After completion of study treatment, patients are followed up at 3 and 12 weeks, then every 3 months for 2 years, every 6 months for 3 years, then every 12 months for up to 10 years.