A Pilot Study Using Short-Term Cultured Anti-Tumor Autologous Lymphocytes

This trial is a pilot study of re-infusion of tumor infiltrating lymphocytes (TIL) from a
patient's own tumor to treat metastatic melanoma. In brief, subjects with metastatic melanoma
that has progressed on anti-PD1, anti-PDL1 and/or anti-CTLA-4 therapies will have a
metastatic melanoma tumor resected. TIL will be isolated from that tumor and expanded in
vitro in the presence of interleukin-2 (IL-2) on site at the Yale Advanced Cell Therapy
Laboratories. Subjects will then undergo myelosuppressive chemotherapy and then unselected
TIL will be re-infused into the subject. Following re-infusion, subjects will be treated with
up to 10 doses of intermediate dose IL-2. Subjects will be hospitalized for parts of the
chemotherapy regimen and then for cell infusion and IL-2 treatment. Subjects will then be
followed for safety and tumor response.

Inclusion Criteria:

- 1. Histologically or cytologically confirmed metastatic melanoma with at least one
lesion that is resectable for TIL generation (at least 1.5 cm in diameter). Subjects
must have measurable or evaluable disease.

2. Clinical performance status of ECOG 0 or 1 at the time of surgical harvest.
Assessment by the treating physician that ECOG performance status of no higher than 2
can be maintained at least for the period of cell generation, lymphoablation, cell
infusion and IL-2 administration (for at least 6 weeks following cell harvest)

3. Tumor that is not responsive to prior therapy with a PD-1/PD-L1 antagonist alone or
in combination with anti-CTLA-4

4. BRAF mutation status must be known prior to cell harvest; for subjects with BRAF
V600E or V600K mutations, there must have been at least one site of disease
progression during treatment with an approved BRAF inhibitor (dabrafenib or
vemurafenib), and in the opinion of the investigator must be able to tolerate
withholding of BRAF inhibitor treatment for the period between initiation of
lymphoablation and recovery of cell counts following TIL infusion.

5. ≥ 18 years of age.

6. If indicated, willing to practice birth control during treatment and for 4 months
after receiving the preparative regimen.

7. Able to understand and sign the Informed Consent Document

8. Hematology: Absolute neutrophil count ≥ 1000/mm3 without support of filgrastim
Normal WBC (> 3000/mm3). Hemoglobin ≥ 8.0 g/dl (can be transfused to this level)
Platelet count greater than 75,000/mm3

9. Serology: Seronegative for HIV antibody. (The experimental treatment being
evaluated in this protocol depends on an intact immune system. Subjects 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
HTLV-1 and HTLV-2 antibodies Seronegative for hepatitis B or hepatitis C. Seronegative
for syphilis Seropositive for EBV (the risk for post-transplant lymphoproliferative
disorder is significantly higher for EBV- subjects who receive EBV+ blood products
after myelosuppressive therapy).

10.Chemistry: Serum ALT/AST < five times the upper limit of normal. Serum creatinine ≤
2.0 mg/dl. Total bilirubin ≤ 2 mg/dl, except in subjects with Gilbert's Syndrome, who
must have a total bilirubin ≤ 3 mg/dl.

11. At least 7 days must have elapsed since any prior systemic therapy at the time the
patient receives the preparative regimen, and toxicities must have recovered to ≤
grade

1 (except for toxicities such as alopecia or vitiligo and certain immune checkpoint
inhibitor toxicities as noted in #12). Subjects may have undergone minor surgical
procedures within the past 3 weeks, as long as all toxicities have recovered to ≤
grade

1 or as specified in the eligibility criteria in Section 3.1.

12. Subjects who have received any anti-CTLA-4, anti-PD-1 or anti-PD-L1 antibody and
experienced treatment- related colitis must have complete resolution of
diarrhea/colitis as assessed by clinical history. For adrenal insufficiency and
hypothyroidism, subjects must be on stable doses of prednisone (≤10 mg daily) and/or
levothyroxine, respectively. All other immune checkpoint toxicity must have resolved
to ≤ grade 1 as assessed by history or exam with the exception of vitiligo, or
cardiac, neurologic or pulmonary toxicity, which must have resolved to grade 0.

Exclusion Criteria:

1. Prior cell transfer therapy that included non-myeloablative or ablative chemotherapy.

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

3. Systemic steroid therapy required prednisone > 10 mg daily or its equivalent.

4. Any contraindication to neutropenia or thrombocytopenia for up to 2 weeks (no active
major infection, no site of active, clinically significant bleeding)

5. Active coagulation disorders

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

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

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

9. Any patient known to have an LVEF ≤ 45%. Also:

Clinically significant atrial and/or ventricular arrhythmias including but not limited
to:

atrial fibrillation, ventricular tachycardia, second or third degree heart block.

Ischemia found on a cardiac stress echocardiogram or a stress-MUGA

10. Documented FEV1 less than or equal to 60% predicted tested in subjects with:

A prolonged history of cigarette smoking Symptoms of respiratory dysfunction

11. Active second malignancy