Tumor-Infiltrating Lymphocytes After Combination Chemotherapy in Treating Patients With Metastatic Melanoma

PRIMARY OBJECTIVES:

I. Examine the anti-tumor efficacy of cellular adoptive immunotherapy in metastatic melanoma
patients using autologous tumor-infiltrating lymphocytes with a lymphodepleting conditioning
regimen of cyclophosphamide and fludarabine (fludarabine phosphate), and followed by adjuvant
high-dose interleukin (IL)-2 (aldesleukin).

SECONDARY OBJECTIVES:

I. Determine the in vivo persistence of transferred tumor-infiltrating lymphocytes.

II. Examine the safety of cellular adoptive immunotherapy in melanoma patients using
autologous tumor-infiltrating lymphocytes, preceded by a lymphodepleting conditioning regimen
of cyclophosphamide and fludarabine, and followed by adjuvant high-dose IL-2.

III. Evaluate for molecular tumor markers and immunohistochemical features that correlate
with in vivo persistence and anti-tumor efficacy.

OUTLINE:

Patients receive cyclophosphamide intravenously (IV) on days -7 to -6 and fludarabine
phosphate IV on days -5 to -1. Patients undergo TIL infusion over 30-60 minutes on day 0 and
receive aldesleukin IV every 8 hours on days 1-5 for up to a maximum of 14 doses.

After completion of study treatment, patients are followed up at 6, 12, and 24 weeks.

Inclusion Criteria:

Step I Inclusion Criteria:

- Stage IV melanoma or stage III melanoma that is unlikely to be cured by surgery

- Able to tolerate high-dose cyclophosphamide, fludarabine and high-dose IL-2

- Eastern Cooperative Oncology Group (ECOG) performance status of 0-1

- Patients must have a magnetic resonance imaging (MRI), computed tomography (CT), or
positron emission tomography (PET) of the brain within 2 months before consenting if
known history of brain metastasis or if clinically indicated; if new lesions are
present, principal investigator (PI) or designee should make final determination
regarding enrollment

- Patients must have a site of metastatic disease that can be safely resected or
biopsied for tissue sufficient for TIL harvest

Step II Inclusion Criteria:

- Patients must have measurable metastatic melanoma

- Able to tolerate high-dose cyclophosphamide, fludarabine, and high-dose IL-2

- ECOG performance status of 0-1

- Patients must have brain imaging by MRI, CT or PET within 30 days prior to
lymphodepletion; patients may have asymptomatic brain lesions that are =< 1 cm each,
lesions that are > 1 cm that have been irradiated and in the opinion of the
investigator no longer represents active disease will also be allowed

- A functional cardiac test (e.g., stress treadmill, stress thallium, multigated
acquisition scan (MUGA), dobutamine echocardiogram) to rule out cardiac ischemia
within 4 months prior to lymphodepletion is required for all patients

- Pulmonary function tests (PFTs) are required of all patients within 4 months prior to
lymphodepletion; forced expiratory volume (FEV)1 and forced vital capacity (FVC) must
be >= 65% predicted and diffusion lung capacity for carbon monoxide (DLCO) must be >=
50% predicted

- Patients must have their tumor sent for v-Raf murine sarcoma viral oncogene homolog
B1(BRAF) mutational analysis

- Patients must have adequate TIL (at least 40 x 10^6 cells at the pre-expansion stage)

Exclusion Criteria:

Step I Exclusion Criteria:

- Men or women of reproductive ability who are unwilling to use effective contraception
or abstinence for 4 months after treatment

- Calculated creatinine clearance (estimated glomerular filtration rate [eGFR]) < 60
ml/min; EGFR values can be determined by either Modification of Diet in Renal Disease
(MDRD) or Cockcroft-Gault equation based on the investigator's discretion

- Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) > 3 x upper limit of
normal

- Total bilirubin > 2.0 mg/dl, except in patients with Gilbert's syndrome whose total
bilirubin must not exceed 3.0 mg/dl) deemed by investigator to be irreversible

- FEV1 < 65% predicted, FVC < 65% of predicted, DLCO (corrected for hemoglobin [Hgb]) <
50% predicted); pulmonary function tests (PFTs) within 4 months prior to consent for
Step I will be required for patients with underlying risk factors such as smoking
history > 10 pack years, or a history of pre-existing symptomatic lung disease (not
including melanoma metastases to the lung)

- Pre-existing known cardiovascular abnormalities as defined by any one of the
following:

- Congestive heart failure

- Clinically significant hypotension

- Cardiac ischemia, or symptoms of coronary artery disease

- Presence of cardiac arrhythmias on electrocardiogram (EKG) requiring drug therapy

- Ejection fraction < 45% (echocardiogram or MUGA), although any patient with an
ejection fraction between 45-49% must receive clearance by a cardiologist to be
eligible for Step II of the trial

- Clinically significant autoimmune disorders or conditions of immunosuppression;
patients with acquired immunodeficiency syndrome (AIDS) or human immunodeficiency
virus (HIV)-1 associated complex or known to be HIV antibody seropositive or known to
be recently polymerase chain reaction (PCR)+ for hepatitis B or C are not eligible for
this study; the severely depressed or altered immune system found in these patients
and the possibility of premature death would compromise study objectives

- Patients with active systemic infection requiring intravenous antibiotics

- Clinically significant psychiatric disease which, in the opinion of the PI or
sub-investigator (I), would render immunotherapy and its potential sequelae unsafe or
compliance with procedural requirements unlikely

Step II Exclusion Criteria:

- Pregnant women, nursing mothers, men or women of reproductive ability who are
unwilling to use effective contraception or abstinence; women of childbearing
potential must have a negative pregnancy test within 14 days prior to entry; patients
of both genders must practice birth control during treatment and for four months after
treatment

- Calculated creatinine clearance (eGFR) < 60 ml/min; EGFR values can be determined by
either MDRD or Cockcroft-Gault equation based on the investigator's discretion

- AST/ALT > 3 x upper limit of normal

- Total bilirubin > 2.0 mg/dl, except in patients with Gilbert's syndrome whose total
bilirubin must not exceed 3.0 mg/dl)

- Clinically significant pulmonary dysfunction (FEV1< 65% predicted or FVC < 65% of
predicted, DLCO (corrected for Hgb) < 50% predicted)

- Pre-existing known cardiovascular abnormalities as defined by any one of the
following:

- Congestive heart failure

- Clinically significant hypotension

- Cardiac ischemia, or symptoms of coronary artery disease

- Presence of cardiac arrhythmias on EKG requiring drug therapy

- Ejection fraction < 45%, although any patient with an ejection fraction between
45-49% must receive clearance by a cardiologist to be eligible for Step II of
this trial

- Absolute neutrophil count less than 1000/mm^3

- Platelet count less than 100,000/mm^3

- Hemoglobin less than 10.0 g/dl

- Untreated central nervous system metastases that are either symptomatic or greater
than 1 cm at time of therapy; lesions that are > 1cm that have been irradiated and in
the opinion of the PI or sub-I no longer represent active disease may be allowed

- Patients with systemic infections requiring active therapy within 72 hours of
lymphodepletion

- Systemic cancer therapy (standard or experimental), including cytotoxic chemotherapy
or IL-2, received less than 4 weeks or checkpoint blocking agents (e.g., cytotoxic
T-lymphocyte protein [CTLA]-4 or programmed cell death protein [PD]1/PD-ligand [L]1
inhibitors) received less than 6 weeks prior to lymphodepletion, with the exception of
targeted therapies

- Commercially available, molecularly targeted therapies (e.g., dabrafenib, trametinib,
vemurafenib, imatinib) taken within 7 days prior to lymphodepletion

- Clinically significant autoimmune disorders or conditions of immunosuppression;
patients with AIDS or HIV-1 associated complex or known to HIV antibody seropositive
or known to be recently PCR+ for hepatitis B or C virus are not eligible for this
study; virology testing will be done within 6 months of T cell infusion; the severely
depressed or altered immune system found in these patients and the possibility of
premature death would compromise study objectives

- Prior treatment with systemic steroids within 4 weeks prior to lymphodepletion (except
for physiologic replacement doses for adrenal insufficiency, premedication for
contrast allergies for scans, and for drug fever related to targeted therapy)

- Any other significant medical or psychological conditions that would make the patient
unsuitable candidate for cell therapy at the discretion of the PI