A Prospective Randomized and Phase 2 Trial for Metastatic Melanoma Using Adoptive Cell Therapy With Tumor Infiltrating Lymphocytes Plus IL-2 Either Alone or Following the Administration of Pembrolizumab

Background:

- Adoptive cell therapy (ACT) using autologous tumor infiltrating lymphocytes (TIL) can
mediate the regression of bulky metastatic melanoma when administered along with highdose
aldesleukin (IL-2) following a non-myeloablative lymphodepleting chemotherapy

preparative regimen consisting of cyclophosphamide and fludarabine.

- Pembrolizumab, a monoclonal antibody that binds to PD-1 and blocks the PD-1/PD-L1 axis,
facilitates the activity of anti-tumor lymphocytes in the tumor micro environment.
Pembrolizumab administration can result in objective tumor responses in patients with

metastatic melanoma and is approved for use by the FDA for the treatment of these patients.

- Administered TIL express low levels of PD-1, though PD-1 can be re-expressed on TIL in
vivo following TIL administration

- In pre-clinical models, the administration of an anti-PD1 antibody enhances the
anti-tumor activity of transferred T-cells.

Objectives:

- To determine in a prospective randomized trial whether the addition of pembrolizumab to
the standard non-myeloablative conditioning regimen, TIL and high dose IL-2 can improve
complete response rates in patients with metastatic melanoma who have received prior
anti PD-1/PD-L1 therapy (Cohort 1)

- To determine the complete response rate to the standard non-myeloablative conditioning
regimen, TIL, high dose IL-2 in combination with pembrolizumab in patients with
metastatic melanoma who have not received prior therapy with anti PD-1/PD-L1 (Cohort 2)

Eligibility:

- Age greater than or equal to 16 and less than or equal to 70 years

- Evaluable metastatic melanoma

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

- No allergies or sensitivities to high-dose aldesleukin administration

- No concurrent major medical illnesses or any form of immunodeficiency

Design:

- Patients with metastatic melanoma will have lesions resected for TIL

- Patients will be assigned to 2 cohorts:

- Cohort 1 patients who are refractory to treatment with anti PD-1/PD-L1

- Cohort 2 patients who have not received treatment with PD-1/PD-L1

- After TIL growth is established:

- Patients who are assigned to Cohort 1 will be randomized to either receive or not
receive pembrolizumab in combination with the standard Adoptive Cell Therapy (ACT)
with TIL (non-myeloablative conditioning regimen, TIL and high dose IL-2)

- Patients who are assigned to Cohort 2 will all receive the standard ACT with TIL in
combination with pembrolizumab

- Pembrolizumab will be administered immediately prior to TIL administration and continue
for 3 additional cycles.

- Up to 170 patients may be enrolled over 3-4 years.

-INCLUSION CRITERIA:

1. Measurable metastatic melanoma with at least one lesion that is resectable for TIL
generation.

2. Confirmation of diagnosis of metastatic melanoma by the Laboratory of Pathology of
NCI.

3. Patients must have received at least one prior therapy for metastatic melanoma.

4. Patients with 3 or fewer brain metastases that are less than 1 cm in diameter and
asymptomatic are eligible. Lesions that have been treated with stereotactic
radiosurgery must be clinically stable for 1 month after treatment for the patient to
be eligible. Patients with surgically resected brain metastases are eligible.

5. Greater than or equal to 16 years of age and less than or equal to 70 years of age.

6. All participants and/or their parents or legally authorized representatives must sign
a written informed consent. Assent will be obtained for all participants under the age
of 18 years.

7. All participants greater than or equal to 18 years of age or older must be willing to
sign a durable power of attorney

8. Clinical performance status of ECOG 0 or 1.

9. 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 treatment.

10. 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 are less responsive to
the experimental treatment and more susceptible to its toxicities.)

- 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.

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

12. Hematology

- Absolute neutrophil count greater than 1000/mm3 without the support of filgrastim

- WBC greater than or equal to 3000/mm3

- Platelet count greater than or equal to 100,000/mm3

- Hemoglobin > 8.0 g/dl

13. Chemistry:

- Serum ALT/AST less than or equal to 2.5 times the upper limit of normal

- Serum Creatinine less than or equal to 1.6 mg/dl

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

14. 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)

15. Patients must demonstrate progressive disease at the time of treatment. (Note:
Patients who have received tyrosine kinase inhibitors (e.g. vemurafinib) may be
treated if they present with stable disease at the time of treatment).

16. Subjects must be co-enrolled in protocol 03-C-0277.

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

3. 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).

4. Active systemic infections (e.g.: requiring anti-infective treatment), coagulation
disorders or any other active major medical illnesses.

5. History of major organ autoimmune disease

6. Concurrent systemic steroid therapy.

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

8. Grade 3 or 4 Major organ Immune-related Adverse Events (IRAEs) following treatment
with anti PD-1/PD-L1.

9. History of coronary revascularization or ischemic symptoms.

10. Documented LVEF of less than or equal to 45%; note: testing is required in patients
with:

- Age greater than or equal to 65 years old

- Clinically significant atrial and or ventricular arrhythmias including but not
limited to: atrial fibrillation, ventricular tachycardia, second or third degree
heart block or have a history of ischemic heart disease, chest pain.

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. Patients who are receiving any other investigational agents.