Prospective Randomized Study of Cell Therapy for Metastatic Melanoma Using Short-Term Cultured Tumor Infiltrating Lymphocytes Plus IL-2 Following Either a Non-Myeloablative Lymphocyte Depleting Chemotherapy Regimen Alone or in Conjunction w/1200 TBI

Background:

- Adoptive cell therapy (ACT) using autologous tumor infiltrating lymphocytes can mediate
the regression of bulky metastatic melanoma when administered along with high-dose
aldesleukin (IL-2) following a non-myeloablative lymphodepleting chemotherapy
preparative regimen consisting of cyclophosphamide and fludarabine.

- In a series of consecutive trials using this chemotherapy preparative regimen alone or
with 2 Gy or 12 Gy total body irradiation (TBI) objective response rates using RECIST
criteria were 49%, 52%, and 72%, respectively. Complete regression rates in these three
consecutive trials were 12%, 20%, and 40%, respectively strongly suggesting that the
addition of TBI could improve the complete regression rate. Of the 20 complete
regressions seen in this trial, 19 are on-going at 37 to 82 months.

- Because of the complexity of developing selected TIL for use in adoptive transfer, we
have recently developed a simplified method for producing TIL that is more applicable to
use in outside institutions. Utilizing young TIL cells (sometimes with CD8 purification)
in 105 patients, the objective response rate was 34% with a 6.6 % incidence of complete
regressions. All patients in this trial received the cyclophosphamide fludarabine
regimen alone.

- Because of the strong suggestion that the addition of TBI to the chemotherapy regimen
could increase durable, complete regression rates in patients with metastatic melanoma,
we are now attempting to definitively determine whether the addition of TBI to the
chemotherapy preparative regimen can improve complete response rates, and overall
survival in patients receiving young TIL .

Objectives:

-To determine, in a prospective randomized trial, the complete response rate and survival of
patients with metastatic melanoma receiving ACT using young TIL plus aldesleukin treatment
following either a chemotherapy preparative regimen alone, or the same chemotherapy
preparative regimen plus TBI.

Eligibility:

-Patients who are 18 years or older must have:

- Evaluable metastatic melanoma;

- Metastatic melanoma lesion suitable for surgical resection for the preparation of TIL;

- No contraindications to high-dose aldesleukin administration or total body irradiation;

- No concurrent major medical illnesses or any form of immunodeficiency

Design:

-Patients with metastatic melanoma will have lesions resected and after TIL growth is
established patients with will be prospectively randomized to receive ACT with young TIL plus
aldesleukin following either a non-myeloablative chemotherapy preparative regimen or this
same regimen plus TBI.

- INCLUSION CRITERIA:

1. Measurable metastatic melanoma with at least one lesion that is resectable for
TIL generation. The lesion must be of at least 1cm in diameter that can be
surgically removed with minimal morbidity (defined as any operation for which
expected hospitalization less than or equal to 7 days).

2. Patients with 3 or less brain metastases are eligible. Note: If lesions are
symptomatic or greater than or equal to 1 cm each, these lesions must have been
treated and stable for 3 months for the patient to be eligible.

3. Greater than or equal to 18 years of age and less than or equal to 66 years of
age.

4. Willing to practice birth control during treatment and for four months after
receiving all protocol related therapy.

5. Life expectancy of greater than three months

6. Willing to sign a durable power of attorney.

7. Able to understand and sign the Informed Consent Document

8. Clinical performance status of ECOG 0 or 1.

9. Hematology:

- Absolute neutrophil count greater than 1000/mm(3)

- Hemoglobin greater than 8.0 g/dl

- Platelet count greater than 100,000/mm(3)

j. Serology:

- Seronegative for HIV antibody. (The experimental treatment being evaluated in this
protocol depends on an intact immune system. Patients who are HIV seropositive can
have decreased immune competence and thus be less responsive to the experimental
treatment and more susceptible to its toxicities.)

- Seronegative for hepatitis B antigen, or hepatitis C antibody or antigen.

k. Chemistry:

- Serum ALT/AST less than three times the upper limit of normal.

- Calculated creatinine clearance (eGFR) > 50 ml/min.

- Total bilirubin less than or equal to 2 mg/dl, except in patients with

Gilbert s Syndrome who must have a total bilirubin less than 3 mg/dl.

l. More than four weeks must have elapsed since any prior systemic therapy at the time of
randomization, and patients toxicities must have recovered to a grade 1 or less (except for
alopecia or vitiligo). Patients must have stable or progressing disease after prior
treatment.

Note: Patients may have undergone minor surgical procedures within the past 3 weeks, as
long as all toxicities have recovered to grade 1 or less or as specified in the inclusion
criteria.

m. Six weeks must have elapsed since any prior anti-CTLA4 antibody therapy to allow
antibody levels to decline.

Note: Patients who have previously received ipilimumab or tremelimumab, anti- PD1 or
anti-PD-L1 antibodies, and have documented GI toxicity must have a normal colonoscopy with
normal colonic biopsies.

EXCLUSION CRITERIA:

1. Prior cell transfer therapy which included a non-myeloablative or myeloablative
chemotherapy regimen.

2. Women of child-bearing potential who are pregnant or breastfeeding because 10 of the
potentially dangerous effects of the preparative chemotherapy on the fetus or infant.

3. Systemic steroid therapy requirement.

4. Active systemic infections, coagulation disorders or other active major medical
illnesses of the cardiovascular, respiratory or immune system, as evidenced by a
positive stress thallium or comparable test, myocardial infarction, cardiac
arrhythmias, obstructive or restrictive pulmonary disease.

5. Any form of primary immunodeficiency (such as Severe Combined Immunodeficiency Disease
and AIDS).

6. Opportunistic infections (The experimental treatment being evaluated in this protocol
depends on an intact immune system. Patients who have decreased immune competence may
be less responsive to the experimental treatment and more susceptible to its
toxicities.)

7. History of severe immediate hypersensitivity reaction to any of the agents used in
this study.

8. History of coronary revascularization or ischemic symptoms.

9. Any patient known to have an LVEF less than or equal to 45%.

10. In patients > 60 years old, documented LVEF of less than or equal to 45%.

11. Documented FEV1 less than or equal to 60% predicted tested in patients with:

- A prolonged history of cigarette smoking (20 pk/year of smoking within the past 2
years)

- Symptoms of respiratory dysfunction

12. Prior radiation therapy that, in the judgment of the radiation oncologist, precludes
the administration of total body irradiation.