Use of IL-15 After Chemotherapy and Lymphocyte Transfer in Metastatic Melanoma

Background:

- Tumor Infiltrating Lymphocytes (TIL) can mediate the regression of bulky metastatic
melanoma when administered to the autologous patient along with high-dose aldesleukin
(IL-2) following a non-myeloablative lymphodepleting chemotherapy preparative regimen.

- In our analysis of factors that relate to the ability of this treatment to mediate
objective responses, we have found a highly significant inverse correlation between
reconstitution of CD4+ Foxp3+ T regulatory cells and the likelihood of achieving an
objective response.

- IL-2 administration has been shown to increase the number of T regulatory cells and in
our trials we have found a direct relationship between the number of IL-2 doses and the
reconstitution of patients at one week with CD4+ Foxp3+ T regulatory cells.

- Interleukin 15 (IL-15) is a strong T cell growth factor, but unlike IL-2, IL-15 is not
involved in the generation and maintenance of CD4+ Foxp3+ T regulatory cells that can
inhibit immune reactions.

- In pre-clinical adoptive cell transfer studies utilizing a murine melanoma model, the
administration of IL-15 following adoptive cell transfer improved anti-tumor effects.

Objectives:

- The primary objective of this trial is to determine the safety, toxicity, and maximum
tolerated dose of intravenous recombinant IL-15 administered as a daily intravenous
bolus for 10 consecutive days in patients with metastatic melanoma who have received a
lymphodepleting chemotherapy regimen and adoptive transfer of tumor infiltrating
lymphocytes.

- An additional primary objective is to determine whether this combination is able to
produce a modest number of clinical responses.

- The secondary objective involves the determination of the level of reconstitution of T
regulatory cells in patients who receive cell transfer followed by IL-15 and to
determine the pharmacokinetics of IL-15 levels in the serum following intravenous
administration.

Eligibility:

- Patients greater than or equal to 18 years old with pathologically confirmed diagnosis
of metastatic melanoma.

- Patients with measurable disease, absolute neutrophil count greater than 1000/mm(3) and
platelet count greater than 100,000/mm(3).

- No serious comorbid conditions such as active systemic infections, coagulation
disorders, or other active major medical illnesses of the cardiovascular, respiratory
or immune systems.

Design:

- Patients with metastatic melanoma will undergo resection to obtain tumor for generation
of autologous TIL cultures.

- Patients will receive a non-myeloablative lymphodepleting preparative regimen
consisting of cyclophosphamide and fludarabine followed by the administration of
autologous Young TIL. In the phase 1 portion of this study, patients will receive
recombinant human IL-15 at doses of 0.25, 0.5, 1 or 2 micrograms per kilogram give
intravenously daily for 10 days starting on the day of cell transfer. One patient will
be treated at the first dose level, if this patient experiences a DLT, additional
patients will be treated at the dose to confirm that no greater than 1/6 patients have
DLT propr to proceeding to the next higher level. If 2 DLTs are encountered in this
cohort, the study will be terminated. In all other cohorts, groups of three to six
patients will receive recombinant human IL-15. Should a single patient experience a
dose limiting toxicity due to the cell transfer at a particular dose level, additional
patients will be treated at the dose to confirm that no greater than 1/6 patients have
a DLT prior to proceeding to the next higher level. If a level 2 or more DLTs in 3-6
patients has been identified, three additional patients will be accrued at the
next-lowest dose, for a total of 6, in order to further characterize the safety of the
maximum tolerated dose prior to starting the phase 2 portion. In the phase 2 perotion
of this study, patients will receive a non-myeloablative lymphodepleting preparative
regimen consisting of cyclophosphamide and fludarabine followed by the administration
of autologous Young TIL and IL-15 at the MTD established in the phase 1 portion.

- Studies will be performed to determine the reconstitution of patients with T regulatory
cells and to determine the pharmacokinetics of IL-15 concentration in serum.

- INCLUSION CRITERIA:

1. Measurable metastatic melanoma with available autologous TIL.

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 age 66.

4. Able to understand and sign the Informed Consent Document

5. Clinical performance status of ECOG 0 or 1.

6. Life expectancy of greater than three months.

7. Patients of both genders must be willing to practice birth control from the time
of enrollment on this study and for up to four months after receiving the
preparative regimen.

8. Serology:

1. 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.)

2. Seronegative for hepatitis B antigen, and seronegative for hepatitis C
antibody. If hepatitis C antibody test is positive, then patient must be
tested for the presence of antigen by RT-PCR and be HCV RNA negative.

3. Women of child-bearing potential must have a negative pregnancy test
because of the potentially dangerous effects of the preparative
chemotherapy on the fetus.

9. Hematology:

1. Absolute neutrophil count greater than 1000/mm(3) without the support of
filgrastim.

2. WBC (> 3000/mm(3)).

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

4. Hemoglobin greater than 8.0 g/dl.

10. Chemistry:

1. Serum ALT/AST less or equal to 2.5 times the upper limit of normal.

2. Serum creatinine less than or equal to 1.6 mg/dl.

3. Total bilirubin less than or equal to 1.5 mg/dl, except in patients with
Gilbert's Syndrome who must have a total bilirubin less than 3.0 mg/dl.

11. More than four weeks must have elapsed since any prior systemic therapy at the
time the patient receives the preparative regimen, and patients' toxicities must
have recovered to a grade 1 or less (except for toxicities such as alopecia or
vitiligo).

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 eligibility criteria.

12. Six weeks must have elapsed from the time of any antibody therapy that could
affect an anti cancer immune response, including anti-CTLA4 antibody therapy, at
the time the patient receives the preparative regimen to allow antibody levels
to decline.

13. Patients who have previously received any anti-CTLA4 antibody and have
documented GI toxicity must have a normal colonoscopy with normal colonic
biopsies.

EXCLUSION CRITERIA:

1. Women of child-bearing potential who are pregnant or breastfeeding because of the
potentially dangerous effects of the treatment on the fetus or infant.

2. Active systemic infections, coagulation disorders or other major medical illnesses of
the cardiovascular, respiratory or immune system, myocardial infarction, cardiac
arrhythmias, obstructive or restrictive pulmonary disease.

3. Any form of primary immunodeficiency (such as Severe Combined Immunodeficiency
Disease).

4. Concurrent 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).

5. Concurrent systemic steroid therapy.

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

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

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

9. Documented LFEV of less than or equal to 45% tested in patients with:

1. clinically significant atrial and/or ventricular arrhythmias including but not
limited to: atrial fibrillation, ventricular tachycardia, second or third degree
heart block or.

2. age greater than or equal to 60 years old.