Immunotherapy Using Tumor Infiltrating Lymphocytes for Patients With Metastatic Melanoma
Immunotherapy Using Tumor Infiltrating Lymphocytes for Patients With Metastatic Melanoma
Background:

 -  The NCI Surgery Branch has developed an experimental therapy that involves taking white
 blood cells from patients' tumors, growing them in the laboratory in large numbers, and
 then giving the cells back to the patient. These cells are called Tumor Infiltrating
 Lymphocytes, or TIL and we have given this type of treatment to over 400 patients with
 melanoma.

 -  In this trial, we are determining if there is a difference in the response between
 patients who have received prior anti-PD1 treatment to those who have not received this
 prior ant-PD1 treatment.

 Objectives:

 - To determine if there is a difference in the rate of response between patients who have
 received prior anti-PD1 and those who have not.

 Eligibility:

 - Individuals at least 18 years and less than or equal to 70 years of age who have metastatic
 melanoma.

 Design:

 -  Work up stage: Participants will be screened with a physical exam and medical history.
 Blood and urine samples will be collected.

 -  Surgery: Surgery or biopsy will be performed to obtain tumor from which to grow white
 blood cells. White blood cells will be grown from the tumor in the laboratory.

 -  Leukapheresis: Participants will have leukapheresis to collect additional white blood
 cells. (Leukapheresis is a common procedure which removes only the white blood cells
 from the patient.)

 -  Treatment: Participants will receive standard dose chemotherapy to prepare their immune
 system to accept the white blood cells. Participants will receive an infusion of their
 own white blood cells grown from tumor. They will also receive aldesleukin for up to
 five days to boost the immune system s response to the white blood cells. They will stay
 in the hospital for about 4 weeks for the treatment.

 -  Follow up: Patients will return to the clinic for a physical exam, review of side
 effects, lab tests, and scans about every 1-3 months for the first year, and then every
 6 months to 1 year as long as their tumors are shrinking. Follow up visits take up to 2
 days.
Background:

 -  Adoptive cell therapy (ACT) using autologous tumor infiltrating lymphocytes can mediate
 the regression of bulky metastatic melanoma when administered along with high-dose
 aldesleukin (IL-2) following a non-myeloablative lymphodepleting chemotherapy
 preparative regimen consisting of cyclophosphamide and fludarabine.

 -  In a series of consecutive trials using this chemotherapy preparative regimen alone or
 with 2 Gy or 12 Gy total body irradiation (TBI) objective response rates using RECIST
 criteria were 49%, 52%, and 72%, respectively. Of the 20 complete regressions seen in
 this trial, 19 are on-going at 70 to 114 months.

 -  The chemotherapy alone preparative regimen required in-patient treatment and was
 associated with significant neutropenia and thrombocytopenia requiring multiple
 transfusions and treatment for febrile neutropenia.

 Objectives:

 -  With amendment D, to determine if there is a difference in the rate of response between
 patients who have received prior anti-PD1 and those who have not; both groups will
 receive non-myeloablative lymphoid depleting preparative regimen followed by autologous
 young TIL and administration of high dose aldesleukin.

 -  To determine the toxicity of the treatment.

 Eligibility:

 -  Age greater than or equal to 18 and less than or equal to 70 years

 -  Evaluable metastatic melanoma

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

 -  No contraindications to high-dose aldesleukin administration

 -  No concurrent major medical illnesses or any form of immunodeficiency

 Design:

 -  Patients with metastatic melanoma will have lesions resected and after TIL growth is
 established, patients will receive ACT with TIL plus aldesleukin following high dose
 chemotherapy preparative regimen.

 -  Up to 64 patients may be enrolled over 4-5 years.
-INCLUSION CRITERIA:

 1. Measurable metastatic melanoma with at least one lesion that is resectable for TIL
 generation and at least one other lesion that can be measured by RECIST criteria.

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

 3. 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.

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

 5. Ability of subject to understand and the willingness to sign the Informed Consent
 Document

 6. Willing to sign a durable power of attorney.

 7. Clinical performance status of ECOG 0, 1 or 2.

 8. 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.

 9. 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.

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

 11. Hematology:

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

 -  WBC greater than or equal to 3000/mm(3)

 -  Platelet count greater than or equal to 100,000/mm(3)

 -  Hemoglobin > 8.0 g/dl

 12. 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 must have a total bilirubin less than 3.0 mg/dl.

 13. 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).
 Patients must have progressive disease after prior treatment.

 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.

 14. Subjects must be co-enrolled in 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. Concurrent systemic steroid therapy.

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

 7. History of coronary revascularization or ischemic symptoms.

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

 9. 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 history of ischemic heart disease or chest pain.

 10. Patients who are receiving other investigational agents

 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