Melanoma Treatment With White Blood Cells That Destroy MART Expressing Tumor Cells

Background:

- TIL transfer studies in patients with metastatic melanoma following lymphodepletion
have resulted in 50 percent objective response rates with a 10-15 percent rate of
complete responses. Despite these important clinical findings, adoptive cell transfer
has not become widely available for patient treatment. Significant obstacles to this
therapy are the need for invasive surgery and the inability of some patients to
tolerate high dose aldesleukin. Further, the specific characteristics of the T cells
that are responsible for the therapeutic effect of tumor infiltrating lymphocyte (TIL)
are unknown, thus, resulting in significant treatment variability.

- Pre-clinical and correlative clinical studies of adoptive immunotherapy have suggested
putative favorable characteristics for transferred lymphocytes, such as, high avidity
for the target antigen, limited in vitro stimulation, and high expression of CD27+.
However, these characteristics have not been prospectively evaluated in human clinical
trials.

- We have developed a novel non invasive T cell isolation strategy using the heteroclitic
MART-1:26-35(27L) peptide for in vitro sensitization of human PBL and high throughput
quantitative polymerase chain reaction (qPCR) screening to rapidly isolate antigen
specific cluster of differentiation 8 (CD8) + T cells from the cluster of
differentiation 4 (CD4) + T cell depleted peripheral blood repertoire. These isolated T
cells possess the above mentioned favorable characteristics and recognize the native
MART-1:27-35 epitope, an abundantly expressed melanoma antigen presented by human
leukocyte antigen serotype within HLA-A A serotype group (HLA-A2) on the tumor surface.

- The current proposed transfer of these select MART-1:27-35 reactive lymphocytes in
conjunction with a lymphodepleting preparative regimen with or without high dose
aldesleukin would represent a novel therapeutic option for patients with advanced
melanoma and provide a desperately needed option for patients who are not medically
eligible for aldesleukin treatment.

Objectives:

- To determine whether MART-1:27-35 reactive lymphocytes infused with or without the
administration of high-dose aldesleukin may result in clinical tumor regression in
patients with metastatic melanoma receiving a non-myeloablative lymphoid depleting
preparative regimen.

- To evaluate the safety of the treatment in patients receiving the non-myeloablative
conditioning regimen and cell transfer with or without the administration of high-dose
aldesleukin

- To determine the survival in patients, of infused cells following the administration of
the non-myeloablative regimen, using analysis of the sequence of the variable region of
the T cell receptor or flow cytometry (fluorescence activated cell sorting (FACS)).

Eligibility:

-Patients with refractory metastatic melanoma who are greater than or equal to 18 years of
age, are HLA-A2+, who have MART-1:27-35 reactive peripheral blood lymphocytes available and
are physically able to tolerate non-myeloablative chemotherapy. Patients must be refractory
to prior high dose aldesleukin treatment if they are medically eligible to receive it.
Patients who can tolerate high-dose aldesleukin will receive it with cell infusion; those
who cannot tolerate high-dose aldesleukin due to medical comorbidities or refuse high-dose
aldesleukin will receive cell infusion without aldesleukin.

Design:

- Patients will receive a non-myeloablative lymphocyte depleting preparative regimen
consisting of cyclophosphamide (60 mg/kg/day X 2 days intravenous (IV)), fludarabine
(25 mg/m^2/day IV X 5 days).

- Patients will receive intravenous adoptive transfer of MART-1:27-35 reactive peripheral
blood lymphocytes (minimum 1 X 10^8 and up to a maximum of 3 X 10^11 lymphocytes)
followed by high-dose intravenous (IV) aldesleukin (720,000 IU/kg/dose every 8 hours
for up to 15 doses) or no aldesleukin if they are not medically eligible to receive it.

- A complete evaluation of evaluable lesions will be conducted 4-6 weeks after the last
dose of aldesleukin in the aldesleukin arm and 4-6 weeks after the cell administration
in the no aldesleukin arm. Patients will be enrolled into two cohorts. The cohort
receiving high-dose aldesleukin will be conducted using a small optimal two-stage Phase
II design, initially 19 patients will be enrolled, and if 4 or more of the first 19
patients have a clinical response ((partial response ) PR or (complete response) CR),
accrual will continue to 33 patients, targeting a 35 percent goal for objective
response. For the cohort who will not receive aldesleukin, the study will be conducted
as a Minimax two stage phase II trial. Initially 12 evaluable patients will be enrolled
to this cohort, and if 1 or more the first 12 have a response, then accrual would
continue until a total of 21 patients, targeting a 20 percent goal for objective
response.

-INCLUSION CRITERIA:

1. Measurable metastatic melanoma.

2. Confirmation of diagnosis of metastatic melanoma and positivity for melanoma antigens
recognized by T cells (MART) confirmed by the Laboratory of Pathology of the National
Cancer Institute (NCI).

3. 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.

4. Patients must be refractory to high dose aldesleukin treatment.

NOTE: This is not required for patients with non-cutaneous melanoma, patients for
whom high dose aldesleukin is medically contraindicated or for patients who are
unwilling to receive high dose aldesleukin.

5. MART-1:27-35 reactive peripheral blood lymphocytes derived from a leukapheresis.

6. Human leukocyte antigens (HLA-A) 0201 positive.

7. Greater than or equal to 18 years of age and less than or equal to age 70.

8. Both genders must be willing to practice birth control during treatment and for four
months after receiving the preparative regimen.

9. Life expectancy of greater than three months.

10. Willing to sign a durable power of attorney.

11. Able to understand and sign the Informed Consent Document.

12. Clinical performance status of Eastern Cooperative Oncology Group (ECOG) 0 or 1 for
the high-dose aldesleukin cohort or ECOG 0, 1 or 2 for no aldesleukin cohort.

13. Hematology:

- Absolute neutrophil count greater than 1000/mm^3 without support of filgrastim

- Normal white blood cell (WBC) (> 3000/mm^3).

- Hemoglobin greater than 8.0 g/dl

- Platelet count greater than 100,000/mm^3.

14. Serology:

- Seronegative for human immunodeficiency virus (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 or hepatitis C. If hepatitis C antibody test is
positive, the patients must be tested for the presence of antigen by reverse
transcription polymerase chain reaction (RT-PCR) and be hepatitis C virus
ribonucleic acid (HCV RNA) negative

15. Chemistry:

- Serum alanine aminotransaminase (ALT)/aspartate aminotransaminase (AST) less
than less or equal to 3 times the upper limit of normal.

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

- Total bilirubin less than or equal to 2.0 mg/dl, except in patients with Gilbert
s Syndrome who must have a total bilirubin less than 3 mg/dl.

16. More than four weeks must have elapsed since any prior systemic therapy, including
chemotherapy, immunotherapy, and/or other targeted therapies, 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). Patients may
have undergone minor surgical procedures within the past 3 weeks, as long as patients
meet eligibility criteria

17. Six weeks must have elapsed from the time of any antibody therapy that could affect
an anti cancer immune response, including anti-cytotoxic T-lymphocyte antigen 4
(CTLA4) antibody therapy, so at the time the patient receives the preparative regimen
to allow antibody levels to decline.

18. Patients who have previously received ipilimumab and have documented gastrointestinal
(GI) toxicity must have a normal colonoscopy with normal colonic biopsies.

NOTE: this is only required for patients who will receive high dose aldesleukin.

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. Systemic steroid therapy required.

3. 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.

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

5. 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.)

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

7. The following patients will be excluded from the high-dose aldesleukin arm (but may
be eligible for cells alone arm):

1. History of coronary revascularization or ischemic symptoms

2. Any patient known to have an left ventricular ejection fraction (LVEF) less than
or equal to 45 percent.

3. Documented LVEF of less than or equal to 45 percent tested in patients with:

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

- Age greater than or equal to 60 years old

4. Documented forced expiratory volume in 1 second (FEV1) less than or equal to 60
percent predicted tested in patients with:

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

- Symptoms of respiratory dysfunction

5. Clinically significant patient history which in the judgment of the Principal
Investigator would compromise the patients ability to tolerate aldesleukin