Acral melanoma responds poorly to anti-PD-1 monotherapy. Ori is a HSV-1 derived oncolytic virus expressing granulocyte-macrophage colony-stimulating factor, which has potentiated the efficacy of anti-PD-1 in acral melanoma in the metastatic setting. We conducted a phase Ib trial evaluating ori/tori in resectable stage IIIb-IV (M1a) acral melanoma (NCT04197882). Pts received the neoadjuvant intralesional ori up to 8*107pfu/mL*10mL combined with iv tori 3mg/kg every 2 wks*4–6 doses prior to surgery, followed by the adjuvant iv tori 3 mg/kg every 3 wks for 1 year. The primary endpoints included radiological (per RECIST 1.1) and pathological response rates. The secondary endpoints were 1/2-y recurrence-free survival (RFS) and safety. Thirty patients were enrolled between 07/2019 and 12/2020, with a median age of 57 y.o. (range 21-72), including 14 (47%) males; 12 (40%) with stage IIIB, 14 (47%) with IIIC, and 4 (13%) with IV (M1a) disease. By the last follow-up in 01/2022, all pts have completed the neoadjuvant part, 27 (90%) completed the surgery and tori adjuvant part (the remaining 3 abrogated surgeries due to disease progression). The median follow-up time was 19 months (IQR 15-25). The radiological and pathological (among those who underwent surgeries only) objective response rate was 36.7% (11/30) (95%CI 19.9-56.1) and 77.8% (21/27) (95%CI 57.7-91.4), and that of complete response rate was 3.3% (1/30) (95%CI 0-17.2) and 14.8% (4/27) (95%CI 4.2-33.7), respectively. The 1-y RFS rate was 80.0% (95%CI 66.9-95.7). This combo was well tolerated. Although all pts experienced adverse events (AEs), most were of grade 1/2 (25/30, 83%). Five patients (17%) developed grade 3 AEs, including 2 soft tissue infections, 1 transaminitis, 1 peripheral neuropathy and 1 neutropenia. No grade 4 AE was observed. Neoadjuvant ori/tori achieved a high pathologic response rate, an impressive 1-y RFS rate, and was well-tolerated in patients with resectable stage IIIB-IV (M1a) acral melanoma. Although longer follow-up is in need, this combo warrants further evaluation in this melanoma subtype.

Tilsotolimod (IMO-2125), an investigational Toll-like receptor 9 agonist, activates innate and adaptive immune responses and rapidly upregulates Type I IFN and dendritic cell activation following intratumoral injection. ILLUMINATE-204 was a phase 1/2 study of tilsotolimod with ipilimumab in patients with advanced melanoma following progression on or after anti-PD-1 therapy. Adults with unresectable or metastatic melanoma that progressed on or after a PD-1 inhibitor, an accessible tumor for intratumoral administration of tilsotolimod, and ≤ 2 lines of prior therapy (≤ 3 if BRAF-mutant) were eligible. Prior ipilimumab was allowed. Tilsotolimod was administered to a single tumor during weeks 1, 2, 3, 5, 8, and 11; ipilimumab was administered per the product label. The primary objective of the phase II portion was to assess preliminary clinical activity at the recommended phase II dose (RP2D). A total of 62 patients were treated with tilsotolimod in combination with ipilimumab. Of these, 52 received the RP2D of 8 mg, and 49 were evaluable for efficacy. The median OS was 21.0 months (95% confidence interval (CI): 9.8 - not reached [NR]), and the overall response rate per RECIST v1.1 was 22.4% (95% CI: 11.8 - 36.6), including 2 complete responses. Median duration of response was 11.4 months (95% CI: 3.3 - NR) with 7/11 responses lasting ≥ 6 months. The disease control rate was 71.4% (95% CI: 56.7 - 83.4). Tumor reduction was observed in injected and non-injected lesions. Analysis of biopsies showed rapid local IFNα gene expression, dendritic cell maturation, and expansion of shared CD8+ T cell clones in injected and non-injected tumors. Grade ≥ 3 AEs were observed in 48% (30/62) of patients, most commonly increased ALT and AST and colitis, and 26% experienced immune-related AEs. No AEs led to treatment discontinuation or death. Tilsotolimod with ipilimumab was generally well-tolerated and demonstrated efficacy in anti-PD-1-refractory advanced melanoma. Activity was observed in injected and non-injected lesions. A phase III study of this combination compared with ipilimumab alone (ILLUMINATE-301; NCT03445533) is ongoing.

Background: SD-101 is a synthetic CpG-ODN agonist of TLR9. Pembrolizumab is a PD-1 inhibitor. SYNERGY-001/KEYNOTE-184 (DV3-MEL-01) assesses the safety and preliminary efficacy of the combination of SD-101 and pembrolizumab in unresectable stage IIIC-IV melanoma. Methods: SD-101 was evaluated as 2 mg/lesion injected into 1-4 lesions and 1 or 8 mg/lesion injected into 1 lesion as 4 weekly doses followed by 7 doses Q3W. Pembrolizumab was administered as 200 mg IV Q3W. Scans were performed every 9 weeks. Responses were assessed per investigator using RECIST v1.1. Responses and Kaplan-Meier analyses of PFS in the ITT population were compared for patients who received ≤ 2 mg/lesion with 8 mg/lesion. Results: 87 patients (1 mg: n = 3; 2 mg: n = 44; 8 mg: n = 40) have been enrolled with similar baseline characteristics: median age 66 years; male: 68%; stage: IIIC=21%; IVM1a/b=52%; IVM1c=28%; LDH > ULN: 21%; treatment naïve: 71%; PD-L1 negative tumors: 49%. SD-101 safety profile comprises flu-like symptoms. Most frequent grade ≥3 treatment-related AEs were headache (8%), myalgia (7%), malaise (6%), fatigue (6%), chills (6%) and injection-site pain (7%). Immune-related AEs were reported in 17%. One unrelated death occurred in the 8 mg group. The best overall response (ORR) in the ≤ 2 mg group (n = 47) was 66% (95% CI: 52, 78) (CR: 11%) and in the 8 mg group (n = 40) was 48% (95% CI: 33, 63) (CR: 5%) with responses in both injected and non-injected lesions. ORR in 57 patients with baseline PD-L1 expression data was: PD-L1 positive: ≤ 2 mg=75% (12/16); 8 mg= 62% (8/13); PD-L1 negative: ≤ 2 mg=85% (11/13); 8 mg=33% (5/15); PD-L1 pending: ≤ 2 mg=44% (8/18); 8 mg = 50% (6/12). PFS was higher in the ≤ 2 mg group (median PFS: ≤ 2 mg=not reached [15.2+ months]; 8 mg=10.4 months, p = 0.034; 6 month PFS rate: ≤ 2 mg=86%; 8 mg=62%). Median follow up in this ongoing study is 4.9 months in the ≤ 2 mg group and 7.3 months in the 8 mg group. Tumor biopsies at Day 29 show increases in CD8+, cytotoxic T cells, and NK cells over baseline. Conclusions: The TLR9 innate immune stimulant, SD-101, in combination with pembrolizumab is showing promising high response rates and prolonged PFS especially in patients who receive lower dose SD-101. The combination has been well tolerated. Clinical trial identification: NCT02521870. Legal entity responsible for the study: Dynavax Technologies Corporation. Funding: Dynavax Technologies Corporation. Disclosure: G.V. Long: Consultancy fees: Array, Pierre Fabre, Novartis, Merck, BMS, Roche. M. Milhem: Advisory board: Blueprint Medicines GIST. A. Amin: Honoraria for speaker's bureau: Merck & Co. C. Lao: Research funding: Merck & Co. M. Chisamore: Employee of Merck & Co. B. Xing, A. Candia, E. Gamelin: Employee of Dynavax Technologies Corporation. R. Janssen: Employee of Dynavax Technologies; Shareholder of Dynavax and Merck stock. A. Ribas: Honoraria for consulting: Dynavax Technologies Corporation, Merck & Co. All other authors have declared no conflicts of interest.

A European Society for Medical Oncology (ESMO)-sponsored expert meeting was held in Paris on 8 March 2018 which comprised 11 experts from academia, 11 experts from the pharmaceutical industry and 2 clinicians who were representatives of ESMO. The focus of the meeting was exclusively on the intratumoral injection/delivery of immunostimulatory agents with the aim of harmonizing the standard terms and methodologies used in the reporting of human intratumoral immunotherapy (HIT-IT) clinical trials to ensure quality assurance and avoid a blurring of the data reported from different studies. The goal was to provide a reference document, endorsed by the panel members that could provide guidance to clinical investigators, pharmaceutical companies, ethics committees, independent review boards, patient advocates and the regulatory authorities and promote an increase in the number and quality of HIT-IT clinical trials in the future. Particular emphasis was placed not only on the development of precise definitions to facilitate a better understanding between investigators but also on the importance of systematic serial biopsies as a driver for translational research and the need for the recording and reporting of data, to facilitate a better understanding of the key processes involved.

AIM:This study sought to determine the role of free radicals derived from mitochondria in the vasculature in the recognized age-related endothelial dysfunction of human skeletal muscle feed arteries (SMFAs). METHODS:A total of 44 SMFAs were studied with and without acute exposure to the mitochondria-targeted antioxidant MitoQ and nitric oxide synthase (NOS) blockade. The relative abundance of proteins from the electron transport chain, phosphorylated (p-) to endothelial (e) NOS ratio, manganese superoxide dismutase (MnSOD) and the mitochondria-derived superoxide (O2-) levels were assessed in SMFA. Endothelium-dependent and endothelium-independent SMFA vasodilation was assessed in response to flow-induced shear stress, acetylcholine (ACh) and sodium nitroprusside (SNP). RESULTS:MitoQ restored endothelium-dependent vasodilation in the old to that of the young when stimulated by both flow (young: 68 ± 5; old: 25 ± 7; old + MitoQ 65 ± 9%) and ACh (young: 97 ± 4; old: 59 ± 10; old + MitoQ: 98 ± 5%), but did not alter the initially uncompromised, endothelium-independent vasodilation (SNP). Compared to the young, MitoQ in the old diminished the initially elevated mitochondria-derived O2- levels and appeared to attenuate the breakdown of MnSOD. Furthermore, MitoQ increased the ratio of p-eNOS to NOS and the restoration of endothelium-dependent vasodilation in the old by MitoQ was ablated by NOS blockade. CONCLUSION:This study demonstrated that MitoQ reverses age-related vascular dysfunction by what appears to be an NO-dependent mechanism in human SMFAs. These findings suggest that mitochondria-targeted antioxidants may have utility in terms of counteracting the attenuated blood flow and vascular dysfunction associated with advancing age.

BACKGROUND:Sentinel-lymph-node biopsy is associated with increased melanoma-specific survival (i.e., survival until death from melanoma) among patients with node-positive intermediate-thickness melanomas (1.2 to 3.5 mm). The value of completion lymph-node dissection for patients with sentinel-node metastases is not clear. METHODS:In an international trial, we randomly assigned patients with sentinel-node metastases detected by means of standard pathological assessment or a multimarker molecular assay to immediate completion lymph-node dissection (dissection group) or nodal observation with ultrasonography (observation group). The primary end point was melanoma-specific survival. Secondary end points included disease-free survival and the cumulative rate of nonsentinel-node metastasis. RESULTS:Immediate completion lymph-node dissection was not associated with increased melanoma-specific survival among 1934 patients with data that could be evaluated in an intention-to-treat analysis or among 1755 patients in the per-protocol analysis. In the per-protocol analysis, the mean (±SE) 3-year rate of melanoma-specific survival was similar in the dissection group and the observation group (86±1.3% and 86±1.2%, respectively; P=0.42 by the log-rank test) at a median follow-up of 43 months. The rate of disease-free survival was slightly higher in the dissection group than in the observation group (68±1.7% and 63±1.7%, respectively; P=0.05 by the log-rank test) at 3 years, based on an increased rate of disease control in the regional nodes at 3 years (92±1.0% vs. 77±1.5%; P<0.001 by the log-rank test); these results must be interpreted with caution. Nonsentinel-node metastases, identified in 11.5% of the patients in the dissection group, were a strong, independent prognostic factor for recurrence (hazard ratio, 1.78; P=0.005). Lymphedema was observed in 24.1% of the patients in the dissection group and in 6.3% of those in the observation group. CONCLUSIONS:Immediate completion lymph-node dissection increased the rate of regional disease control and provided prognostic information but did not increase melanoma-specific survival among patients with melanoma and sentinel-node metastases. (Funded by the National Cancer Institute and others; MSLT-II ClinicalTrials.gov number, NCT00297895 .).

Background: HF10 is a bioselected replication-competent oncolytic virus derived from HSV-1. Herein, we report the safety and efficacy data of HF10+ipilimumab (ipi) combination treatment in a Phase II trial in melanoma. Methods: Ipi naïve patients (pts) with Stage IIIB-IV unresectable melanoma received HF10 injections (inj) into single or multiple dermal, subcutaneous or lymph node tumors (1x107 TCID50/mL, up to 5mL/dose); 4 inj qwk; then up to 15 inj q3wk. Ipi was administered IV (3 mg/kg), q3wk for 4 doses. Tumor responses assessed per irRC at 12, 18, 24, 36 and 48wks. Primary endpoint was Best Overall Response Rate (BORR) at 24wks. Results: Of 46 pts enrolled and treated: 59% men, median age 67 yrs (range 28 to 91); disease stage 20% IIIB, 43% IIIC & 37% IV; therapy (tx) naïve: 57% and ≥ 1 prior cancer tx: 43% (2 pts received prior immune checkpoint inhibitors). Most HF10-related AEs were ≤G2, similar to HF10 monotherapy. 37% had ≥G3 AEs, the majority due to ipi. HF10-related ≥G3 AEs (n = 3) were embolism, lymphedema, diarrhea, hypoglycemia, and groin pain. Of 44 efficacy evaluable pts per irRC, BORR at 24wks was 41% (18% irCR, 23% irPR); disease control rate was 68% (27% irSD). BORR at 48wks was 45% (18% irCR, 27% irPR). BORR at 24wks in tx naïve pts was 50% (17% irCR, 33% irPR) and pts with ≥1 prior therapies was 30% (20% irCR, 10% irPR). BORR in pts with stages IIIB/IIIC/IVM1a (n = 34) and IVM1b/IVM1c (n = 10) were 47% (21% irCR, 26% irPR) and 20% (10% irCR, 10% irPR), respectively. Median PFS was 19mos and 1-year overall survival rate was 85%. Median PFS in tx naïve and pts with ≥1 prior therapies were 19mos and 22mos, respectively; 1-year overall survival rates in tx naïve and pts with ≥1 prior therapies 87% and 82%, respectively. HF10+ipi treatment resulted in a decrease in lesion size by ≥ 50% in 57% of injected lesions (N = 148), 39% of never injected non-visceral lesions (N = 41) and 14% of never injected visceral lesions (N = 22). Complete resolution of lesions occurred in 30% of injected lesions and 20% of never injected non-visceral lesions. Conclusions: The combination HF10 and ipi treatment demonstrated a favorable benefit/risk profile and encouraging antitumor activity in unresectable or metastatic melanoma pts. Clinical trial indentification: NCT02272855. Legal entity responsible for the study: TAKARA BIO INC Funding: TAKARA BIO INC Disclosure: R.H.I. Andtbacka: Receipt of grants/research supports: from Takara, Amgen, Viralytics Receipt of honoraria: from Merck, Novartis, M. Ross: Receipt of honoraria or consultation fees: AMGEN, MERCK, PROVECTUS Participation in a company sponsored speaker’s bureau: AMGEN, M. Taylor: Receipt of honoraria or consultation fees: Bristol Myers Squibb, Eisai Inc, Trillium Pharma, Blue Print Medicines. Participation in a company sponsored speaker’s bureau: Bristol Myers Squibb, Eisai Inc. J. Vetto: Receipt of grants/research supports: none Receipt of honoraria or consultation fees: Castle Biosciences, Novartis Participation in a company sponsored speaker’s bureau: Castle Biosciences, Amgen Stock shareholder (Yes/No): No Spouse/Partner (Yes/No): Yes; salary and stock (Roche) All other authors have declared no conflicts of interest.

T is a herpes simplex virus 1-based oncolytic immunotherapy designed to selectively replicate in tumors, produce GM-CSF, and stimulate antitumor immune responses. I (anti-CTLA-4 Ab) blocks inhibition of antitumor T-cells and improves overall survival (OS) in advanced melanoma. This phase 1b/2 study of T + I evaluates safety and efficacy in unresected stage IIIB-IV melanoma. The 1° endpoint for phase 2 is ORR by immune-related response criteria. Key 2° endpoints are safety, progression-free survival, time to response, duration of response, and OS. Key eligibility criteria are unresectable stage IIIB-IV melanoma, ≤1 prior treatment (tx) if BRAF WT or 2 prior tx if BRAF MT, measurable/injectable tumor(s), and no symptomatic autoimmunity or clinically significant immunosuppression. T was given ≤4x106 plaque forming units (PFU) on d1, w1; ≤4x108 PFU d1, w4, then q2w in arm 1 until no injectable tumors, disease progression, or intolerance. I started with the 3rd dose of T in arm 1 or alone in arm 2 at 3 mg/kg IV q3w x 4. An ORR interim analysis (IA) was performed when 82 patients (pts) had ≥48 w of follow up. 173 pts were randomized: 88 T + I; 85 I. Characteristics for all pts were similar: 54% stage IIIB-IVM1a, 45% IVM1b/c. Median follow up time for 82 pts was 61.2 w (range: 0.14-113.9). Confirmed ORR was 35.7% (T + I) and 17.5% (I); unconfirmed ORR was 50% (T + I) and 27.5% (I; table). Of 165 pts in the safety set (85 T + I, 80 I), most common adverse events (AEs) for T + I, I (%) were fatigue (52, 39), chills (51, 3), diarrhea (39, 34), pyrexia (39, 8), rash (39, 31), and pruritus (38, 35). 20% T + I and 18% I pts had grade 3/4 tx-related AEs. A grade 5 autoimmune hepatitis occurred in the T + I arm (attributed to I per investigator).Tabled 1Confirmed* n (%)Unconfirmed^ n (%)T + I n = 42I n = 40T + I n = 42I n = 40ORR - n (%) (95% CI)15 (35.7) (21.6, 52.0)7 (17.5) (7.3, 32.8)21 (50.0) (34.2, 65.8)11 (27.5) (14.6, 43.9)CR4 (9.5)4 (10.0)6 (14.3)7 (17.5)PR11 (26.2)3 (7.5)15 (35.7)4 (10.0)SD13 (31.0)11 (27.5)7 (16.7)7 (17.5)PD6 (14.3)5 (12.5)11 (26.2)17 (42.5)UE5 (11.9)13 (32.5)0 (0.0)1 (2.5)DCR - n (%) (95% CI)28 (66.7) (50.5, 80.4)18 (45.0) (29.3, 61.5)28 (66.7) (50.5, 80.4)18 (45.0) (29.3, 61.5)*Confirmation of initial CR/PR/PD by subsequent assessment by ≥4 w apart. A CR/PR without confirmation is classified as SD and an unconfirmed PD is classified as UE.^Unconfirmed is response or PD without confirmation requirement.CR: complete response; PR: partial response; SD: stable disease; PD: progressive disease; UE: unable to evaluate; DCR: disease control rate (SD or better). Open table in a new tab *Confirmation of initial CR/PR/PD by subsequent assessment by ≥4 w apart. A CR/PR without confirmation is classified as SD and an unconfirmed PD is classified as UE. ^Unconfirmed is response or PD without confirmation requirement. CR: complete response; PR: partial response; SD: stable disease; PD: progressive disease; UE: unable to evaluate; DCR: disease control rate (SD or better). ORR was higher for T + I vs I alone at this IA. AEs were comparable between arms except for increased fatigue, chills, and pyrexia in the T + I arm.